Severine Kelly
21 Feb 2024 · Coroner Roland Wooderson · Gloucestershire
The coroner's concerns
1. inadequate training of bank staff
“The medical training of certain "bank" staff, at the hospital on 1 October 2022, was not up to date”
2. failure to update risk assessments
“Staff needed to be aware of the need to update risk assessments and take appropriate action following a medical event that could be injurious to a patient”
3. delayed emergency communication
“A doctor, attempting to assist [the deceased] and speak to the 999-emergency service was obliged to leave the patient to use a mobile phone”
4. delayed paramedic response
“A paramedic attending Wotton Lawn hospital was unsure which ward he should attend due to lack of guidance from staff at the hospital”
5. uncertainty about emergency escalation
“There seemed to be uncertainty at which stage of a medical emergency a medical professional should call the ambulance service”
6. non-functional AED clock
“An AED used on the 1 October 2022 appeared not to have a working internal clock”