Oliver Ford
15 Aug 2016 · Coroner Maria Voisin · Avon
The coroner's concerns
1. lack of risk assessment in telephone triage
“That there is a further review of the telephone triage process to specifically consider including a risk assessment”
2. risk assessment not documented
“any risk assessment at all, whether it is formal, informal or indeed based on clinical judgment alone following the triage, is always documented in the Rio notes”
3. insufficient weekend coverage for PCLS service
“am aware that you have considered extending the PCLS service into Saturday”