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recurance

Wendy Hammon

29 Jul 2024 · Coroner Anna Crawford · Surrey

The coroner's concerns

  1. 1. lack of knowledge about rising CRP indicating ischaemia

    “Mrs [name redacted] rising CRP was not noted by any member of the clinical team - whether junior or senior - who saw Mrs [name redacted] during the period from 1 September onwards, despite rising CRP being a potential indicator of ischaemia in patients who are being conservatively managed for small bowel obstruction. The court is concerned that this was not an individual error and may be reflective of a wider lack of knowledge within the team.”
  2. 2. inadequate fluid input and output charts

    “The fluid input and output charts completed for Mrs [name redacted] were inadequate and could not be relied upon to accurately assess her fluid input and output.”
  3. 3. incomplete Early Warning Scores (NEWS2)

    “The Early Warning Scores (NEWS2 Scores) for Mrs [name redacted] were often incomplete.”

Responses

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  • Tavily follow-up web search
  • Postgres and pgvector search
  • Next.js site

Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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Wendy Hammon · Recurance