Michael Giles

“The handover process between shifts was expressed to be different throughout the hospital on different wards. This potentially leads to inconsistency with inadequate information being shared.”

“The absence of a senior review of patients over the weekend was a factor in the suboptimal care given to this patient.”

“There was an acknowledgement within the Trusts investigation that, during the crisis period of this patient's admission there was a lack of leadership from both clinicians and nurses with no one taking responsibility to ensure that tests and investigations were in fact carried out and followed up.”

“The case notes and medical records were (again) inadequate, | have been told on many occasions that the importance of good record-keeping is emphasised to clinicians - sadly in this case yet again the lessons do not appear to be being learned.”