Mark Hinton
30 Apr 2019 · Coroner John Ellery · Shropshire, Telford & Wrekin
The coroner's concerns
1. information not recorded or passed on
“referred to) attended A&E he informed the triage nurse (nurse A) that he had contacted 111 who advised to go to A&E due to possible 'clot'. That information was not recorded or passed on to others.”
2. information not passed to nurse C
“The Staff Nurse (nurse B) who then carried out observations on [the deceased] came to the view that he 'could probably do with a D-Dimer'. That nurse states she passed that information to the next (third) nurse (nurse C).”
3. information not passed to nurse C
“Nurse C states that information was not passed to her. She was unaware that [the deceased] had pain in his calf and therefore had no reason to request bloods, particularly a D-Dimer test, and had no knowledge of them being requested.”
4. request not recorded
“At or around 19:33 hours it appears that bloods, including a D-Dimer test were requested. However there is no record of these (8) test being recorded or who ordered them or why.”
5. D-Dimer test not shown to doctor
“When the attending doctor first saw [the deceased] at 21:06 hours he saw the results of 7 blood tests none of which indicated to him the presence of a possible DVT. The 8th blood test (i.e. the D-Dimer test) was not shown and as there was no record of it having been requested he did not know it was outstanding and nor in his opinion, was it required.”
6. lack of mandatory recording of test requests
“system did not require or mandate the person who requested blood tests, specifically in this case a D-Dimer test, to record that request or the reason for it. There was no alert system which would have alerted the final decision maker of that request.”