Roy Burgess

1. 1. missed opportunities for deteriorating patient escalation

   “The hospital Early Warning System used to identify and escalate a deteriorating patient was not adhered to. This allowed missed opportunities for Mr [name redacted] care to receive Senior Medical reviews which could have altered his management.”

2. 2. inadequate record keeping of escalation inputs

   “Inadequate record keeping by clinician within the Clinical notes. There were numerous examples of care having been escalated by nursing staff to doctors but no record of their input following this escalation was entered in the notes, e.g. on 4'”

3. 3. non-chronological entry of ward round notes

   “Finally, untimed dictated notes of ward rounds, were then entered into the records in a non- chronological order, which was unhelpful and potentially misleading”

No published response was found on judiciary.uk.