Thomas Gibson

1. 1. misinterpretation of ECG results leading to missed diagnosis

   “a narrow focus on the error of three different doctors to interpret two ECGs correctly (rather than any broader consideration of the context in which such misinterpretations occurred) represents a missed opportunity to fully understand the factors that led to Mr [name redacted] discharge from hospital, thus creating a risk of future deaths”

2. 2. lack of communication guidance across specialties and roles

   “there does not appear to be clear guidance available to those working within the Trust as to what is required when communicating (particularly as to test results and a patient's presentation) as between different specialisms and as between different roles within the team”

3. 3. inadequate contextual information for test review

   “there is no specific guidance as to expected minimum standards as to obtaining appropriate context / information for clinicians (whether from the HIVE system or otherwise) when asked to review a single test or investigation result in isolation”

4. 4. missing senior review for incongruous test results

   “there does not currently appear to be any particular requirement in place for a senior review of the patient to take place in circumstances where diagnostic tests undertaken yield results which appear incongruous / unexpected in the context of their presentation”

5. 5. absence of ECG audit before discharge

   “no wider audit of ECGs interpreted in the Emergency Department / Acute Medical Unit prior to discharge of patients appears to have been undertaken”

6. 6. insufficient discharge summary audit

   “no audit as to the sufficiency of detail contained in discharge summaries appears to have been undertaken to date in the light of the issues identified by the Trust's High Impact Learning Assessment”

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