Nadim Butt
7 Apr 2016 · Coroner Ian Smith · Stoke-on-Trent and North Staffordshire
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of serious incident review
“Whilst the hospital sought a review of procedures and protocols the matter was not elevated to a serious untoward incident or root cause analysis where all matters including clinical and nursing decisions were reviewed and subjected to critical examination.”
2. absence of consultant-led on-call rota
“Despite the recognition that a consultant-led out of hours on-call rota is required for patients having undergone surgery, no such rota is yet in place.”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“Whilst the hospital sought a review of procedures and protocols the matter was not elevated to a serious untoward incident or root cause analysis where all matters including clinical and nursing decisions were reviewed and subjected to critical examination.”
Later report
“(5) There is no compulsory training of clinicians required to undertake root cause analysis.”
Responses
No published response was found on judiciary.uk.