Linda Lloyd

1. 1. inadequate triage assessment by junior staff

   “During the Inquiry, I received written evidence a review has taken place further to this incident, and that it is now only the very senior paediatric nurses who are able to triage and that a triage training plan has been implemented which is to be completed by all nurses who triage and is designed to ensure all triage staff are able to assess and direct initial care for patients and ensure they are placed in the most appropriate area post triage.”

2. 2. insufficient staffing resilience

   “I remain concerned that the procedures in place at the hospital are insufficiently robust, and that staffing levels do not provide the Trust with sufficient resilience, to enable the Trust to minimise the risks of further deaths in similar circumstances particularly given the criticisms made by the independent expert and the number of areas of concern he raises.”

3. 3. lack of formal reporting mechanism

   “I indicated to the Properly [name redacted] that I proposed to write to the Trust by way of a report in accordance with the provisions of paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009.”

No published response was found on judiciary.uk.