Joyce Ravenhill
24 Aug 2016 · Coroner Nicholas Rheinberg · Cheshire
The coroner's concerns
1. lack of effective communication of urgent medical need
“Although a summary of the first triage assessment on 26th December 2015 was available to the second triage nurse, there was no facility / operational policy whereby the simple fact that the deceased needed an urgent doctor's appointment could be effectively communicated by the first triage nurse to the second, all information and communication being automatically electronically generated.”
Responses
2016-0303-Response-by-North-West-Ambulance-Service-NHS-Trust.pdf ↗· North West Ambulance Service NHS Trust
Stated action
“Following the initial request for information in support of the Inquest, NWAS carried out an assessment of our involvement in Mrs [name redacted] care. In addition to the matter noted above, some further issues in the call were identified on the part of one of our clinicians in the NHS 111 service. NWAS reported the incident under its StEIS reporting procedure and carried out a full investigation.”