Royston Kemp
2 May 2019 · Coroner Andrew Harris · London Inner (South)
The coroner's concerns
1. swollen leg with temperature difference
“She found one leg more swollen than the other and of a different temperature but took no action”
2. failure to verify concern
“She failed to establish the care assistant's concern or whether she had met the concern before or after her assessment”
3. failure to measure vital signs
“She failed to measure Vital Signs”
4. failure to escalate and refer
“She failed to escalate to medical care or refer, in the process failed to enable a diagnosis of fractured femur to be made”
Responses
No published response was found on judiciary.uk.