Margaret Waylett
19 Dec 2023 · Coroner Nadia Persaud · East London
The coroner's concerns
1. lack of orthopaedic review
“nursing staff requested reviews by the on-call orthopaedic doctors on multiple occasions, without the doctors attending to carry out a review”
2. dangerous orthopaedic staffing
“junior orthopaedic staffing levels in the hospital as "dangerous”
3. unavailable NEWS charts
“NEWS charts were not available on the ward rounds”
4. cumbersome laptops
“laptops on the ward were unwieldy and time consuming”
5. responsibility confusion
“confusion between the doctors as to who was responsible for the patient”
6. delayed orthogeriatrician review
“have considered it necessary for them to receive a referral from the orthopaedic team before they could carry out a review.”
Responses
2023-0532-Response-from-Barts-Health-NHS-Trust.pdf ↗· Barts Health NHS Trust
Stated action
“Staffing levels have been reviewed by the senior doctors in the divisions of medicine and surgery and are felt to be appropriate. Incidents are reviewed and feedback is listened to from junior doctors and taken into account when deciding on future staffing levels.”
Stated action
“A new process has been introduced, in which contact information for on call doctors is displayed in relevant clinical areas so that there is complete clarity about who should be contacted.”
Stated action
“The interaction and interface between the orthopaedic and orthogeriatric teams has been reviewed and updated, to ensure that there is no misunderstanding and that no patient who would benefit from a medical assessment is missed.”
Stated action
“Computers on wheels are also available for use.”