Tom Cribley
9 Oct 2018 · Coroner Julie Goulding · Liverpool and Wirral
This report repeats 2 earlier warnings, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. failure to document rash at triage
“failure to document the rash that [the deceased] presented with when he arrived at AED which was not recorded at triage”
2. failure to complete PIT STOP review
“failure to complete a full "PIT STOP" review”
3. failure to reassess diagnosis
“failure to review the initial diagnosis of gastroenteritis when [the deceased]'s condition continued to deteriorate”
4. failure to handover concerns
“staff to handover clinical concerns to each other and to medical staff including face to face handovers”
5. failure to escalate abnormal blood results
“failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“For new patients being admitted or transferred, there is no requirement for the nurse in charge to review their recent records.”
This report
“the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers”
Identical hazardConfidence 0.90 · high
Earlier report
“that there is still no protocol for face to face medical handover”
This report
“the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers”
Closely relatedConfidence 0.85 · high
This report
“the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers”
Later report
“The inquest heard how there was no system of hand over when junior doctors change from ward to ward.”
Responses
No published response was found on judiciary.uk.