William Atherton
21 Dec 2018 · Coroner Yvonne Blake · Norfolk
The coroner's concerns
1. lack of medical review after ward round
“no medical review of Mr [name redacted] took place after the ward round on 30th”
2. failure to recognise worsening condition
“worsening condition was not recognised by the junior doctor reviewing the blood results”
3. absence of nursing observations
“no nursing observations were carried out in the several hours whilst he waited to go home”
4. missed bowel obstruction warning signs
“potential warning signs of a bowel obstruction were not recognised and acted upon”
5. incorrect EWS documentation
“documentation was incorrectly filled in (early warning scores EWS) and thus the proper escalation of treatment which this should have triggered did not take place”
6. inconsistent EWS scoring across departments
“different department at QEH appear to complete EWS differently results in inconsistent scoring and the potential to not escalate treatment of a patient who needs it”
Responses
No published response was found on judiciary.uk.