Patricia Palin

“Shropdoc personnel, be that Doctors or Urgent Care Practitioners are not able to access the referring patients GP records. This meant that they did not have the full picture of [the deceased]'s past medical history before administering any advice or treatment. This is not a one off isolated incident and applies to every case that is referred to Shropdoc. Evidence was given at the inquest from the Shropdoc Urgent Care Practitioners that it would have assisted them.”

“During the evening of the 1°t October 2017, there were only two A&E Doctors on duty (a third had telephoned in sick ). Too few Doctors were therefore on duty in general to cover patient needs and there did not seem to be in place a programme for trying to get a third Doctor to replace the Doctor who had telephoned in sick.”

“heard evidence that a prescribed drug Ertapenem was not in stock within the A&E department and that led to a delay of some two hours and twenty five minutes until administration. Other suitable alternative drugs were available but not considered.”

“a. Red flag signs of sepsis were missed. b. Leg bandages were not removed to allow full top to toe examination. c. Sepsis six care bundles were not followed in accordance with guidelines.”