Juliet Saunders
18 May 2021 · Coroner Graeme Irvine · East London
The coroner's concerns
1. lack of support for staff dealing with learning disability patients
“The absence of any support for staff within the emergency department during weekends, in dealing with patients with learning disability”
2. poor medical record keeping and documentation
“The poor standard of medical record keeping and documentation within the emergency department and observation unit”
3. lack of supervision for junior doctors
“The failure of systems within the department to allow for the supervision of junior doctors to ensure that complex cases are escalated to more experienced staff”
4. failure to recognise abnormal radiographic findings
“Consecutive failures by medical and radiological staff to recognise abnormal findings within an abdominal radiograph, impacted upon by diagnostic overshadowing”
5. failure to diagnose acute intestinal obstruction
“A lack of clinical curiosity, combined with diagnostic overshadowing meant that there was a reluctance to depart from a queried diagnosis of gastritis which led to the failure to diagnose an acute intestinal obstruction”
6. unsafe patient transfers from emergency department
“A departure from established procedures to ensure the safety of transfers out of the emergency department onto the observation unit”