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recurance

Laxmi Thakker

28 Apr 2016 · Coroner Fiona Wilcox · London Inner West

The coroner's concerns

  1. 1. lack of bedside observation chart

    “Lack of bedside observation chart hinders rather than assists clinical assessment of patients. This represents a real step- back in the provision of patient care.”
  2. 2. lack of training in nursing staff

    “Lack of training at CUH in the nursing staff in relation to the existence of and when to call the”
  3. 3. telephonic communication problems

    “Problems with telephonic communications on the CUH site.”
  4. 4. blood administration system problems

    “Problems with systems in place for the administration of blood at CUH.”
  5. 5. lack of escalation of clinical concerns

    “Lack of escalation of clinical concerns from junior to senior staff at CUH, and in particular that a patient could collapse, be seen by a junior from another treating team and the patient's own senior team not be promptly informed, as well lack of escalation of clinical issues within the same team.”

Responses

No published response was found on judiciary.uk.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error