Michael Newell

1. 1. lack of awareness of decompensated liver failure impact on clinical course

   “the Accident & Emergency staff, neurosurgeons and ENT surgeons of various grades were unaware of the substantial effect that Mr [name redacted] decompensated liver failure would have on his clinical course and subsequent management”

2. 2. lack of knowledge of early hypovolaemia signs

   “the junior ENT surgeons and neurosurgeons showed a startling lack of knowledge of the early signs of hypovolaemia and, if any did realise, made no attempt to treat Mr [name redacted] adequately”

3. 3. lack of recognition of case complexity

   “there was a worrying lack by the ENT surgeons to realise the complexity of the case due to the ongoing haemorrhage, decompensated liver failure and associated coagulopathy”

4. 4. lack of ENT input into mortality review

   “the Trust's ENT team made no input into the mortality review prior to it reaching its conclusions”

5. 5. failure to document and follow clinical management after peri-arrest

   “the conduct of the Nurse in charge of the ward of making no notes after her presence at a peri-arrest, neither seeking or obtaining any direction from the medical team as to future management, not directing any further resuscitation in accordance with documented medical plans in the notes and lack of completion of the fluid balance chart”

No published response was found on judiciary.uk.