Shahan Aman

“A series of miscommunications between; nursing staff, junior and consultant paediatric medical staff resulted in concerns regarding Aman not being properly considered prior to discharge. Staff relied on assumptions that others understood the factors affecting Aman and had a plan to resolve them, this was not the case. Had effective communication occurred it was unlikely that Aman would have been discharged.”

“The doctor who authorised discharge did not satisfy himself of the most recent set of clinical observations and associated Paediatric Early Warning Sign (PEWS) score prior to discharge.”

“The Paediatric Emergency Department was particularly busy that evening, with a combination of high patient numbers and severe acuity of symptoms. The accounts provided by Trust witnesses was that resulted in a pressurised environment and that this was a situation that occurred with an increasing level of frequency over the last two years.”