Sharon Grierson
25 Jan 2018 · Coroner David Roberts · Cumbria
The coroner's concerns
1. lack of appreciation of capnography during CPR
“There was a lack of appreciation of what the capnography was indicating and some lack of understanding of the trace one might expect to see during CPR”
2. lack of coordination and situational awareness
“There was a lack of co-ordination and situational awareness”
3. senior staff de-skilling in crisis management
“It became apparent that senior staff often have little experience of crisis situations and there is a danger that they become 'de-skilled' to some extent as a result”