Sophie Dean

“Consultant's undertaking ward rounds allowed very junior doctors to make the entry from these consultations in the patient records. While there is no concern about this per se, there were numerous key factors missing from these notes. I am concerned that the notes did not fully represent the discussions and assessments that took place, which creates risk.”

“There were other omissions from the medical records for Miss [name redacted] admission.”

“The on-call surgeon used language such as having "pushed the family" into agreeing to surgery on 24 August 2023. There was also evidence that not all options/possibilities were discussed with Miss [name redacted] parents prior to their consenting to surgery. The evidence was that Miss [name redacted] parents may not have fully understood the rationale for surgery or the possibility of conservative management of the issue, prior to the laparotomy on 24 August 2023.”