Peter Anzani
1 May 2025 · Coroner Adam Hodson · Birmingham and Solihull
The coroner's concerns
1. incomplete vital sign observations
“I did not see any record of his pulse, blood pressure or oxygen saturation. The normal practice is to complete these observations, and I would expect this to be done, especially with him presenting with chest issues. However, I am unable to comment why this was not recorded or confirm that these were carried out. (21) This is a learning point for the department, and I have taken steps to ensure this learning is taken forward by theTrust. I have alerted the Sister in charge of the Spinal Injuries”
2. inadequate staff training and incomplete patient records
“There is a real risk of future deaths occurring where staff do not have adequate training and that patient records are not being properly completed”
3. excessive patient waiting times
“evidence that The [name redacted] and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust ("The Trust") have been experiencing difficulties with patient waiting lists - due to both an increase in the quantity of patients being treated and staffing shortages - which has led to patients waiting longer than is reasonable or necessary for reviews and treatments”
4. insufficient funding for workforce expansion
“I heard evidence from representatives of the Trust that they have repeatedly requested additional funds for workforce development and expansion to assist with cutting patient waiting lists and waiting times”