Recurance · prevention of future deaths reports
Pre-inquest brief
Delayed x-ray result review and reporting
The earlier warning
Audrey Daws · 9 Jun 2014 · Andrew Cox, Plymouth, Torbay & South Devon
“once the X-ray was performed, the result was not seen by medical staff for over 24 hours”
What was promised
Stated action 1 · response to Audrey Daws (9 Jun 2014) · stated timescale: none stated
“We have made a number of changes to the handover process, both in relation to medical and nursing procedures.”
What recurred
- 22 Sept 2015 · William Harnell · Andrew Cox · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Audrey Daws · 9 Jun 2014
“once the X-ray was performed, the result was not seen by medical staff for over 24 hours”
Later · William Harnell · 22 Sept 2015
“There was a delay of 5 days in the formal reporting of the original X-ray;”
What happened next
No web check of the stated actions has been published for this chain.