Philip Taylor
17 Dec 2020 · Coroner Alison Mutch · Greater Manchester South
The coroner's concerns
1. dehydration risk not recognised by GP
“Mr [name redacted] was seen by a GP the day before he died. His risk of dehydration was not recognised. The precise observations of the GP were difficult to ascertain at the inquest for a number of reasons.”
2. delayed ambulance transfer due to reliance on national pathfinder tool
“The paramedic attending was a newly qualified paramedic and as a result was using the national pathfinder tool. Mr [name redacted] was scoring for sepsis on the NWAS observations. However, the crew took well over an hour to leave the care home.”
3. care home staff unable to recognise dehydration without guidance
“The staff in the care home were not medically qualified. The inquest heard that their ability to recognise and respond to an escalating risk of dehydration was limited. There was no national 2 guidance to assist care home staff in understanding how to recognise; respond and escalate the risk of dehydration”