Mnayea Al Basman
3 Dec 2024 · Coroner Ian Potter · Inner North London
The coroner's concerns
1. lack of consultant presence over weekend
“The consultant colorectal surgeon was not in the hospital over the weekend of 23/24 March 2024; however, he was able to be contacted if the need arose”
2. inaccurate clinical documentation
“some entries in the clinical notes may have been 'falsely reassuring'”
3. insufficient professional curiosity
“there was a degree of insufficient professional curiosity on the part of some clinicians”
4. absence of overnight monitoring plan
“there should have been a plan in place to closely observe Mr [name redacted] overnight on 24/25 March 2024”
5. incomplete clinical records
“A number of the notes/records in relation to the care provided to Mr [name redacted], particularly over the weekend of 23/24 March 2024, lacked detail”
Responses
2024-0668-Response-from-Royal-Free-London-NHS-Foundation-Trust.pdf ↗· Royal Free London NHS Foundation Trust
Stated action · June 2025
“Education to Nursing and Resident Medical Officer (RMO) teams regarding how and when to escalate to consultant”