Alexander Blewitt

“At the time of Mr [name redacted] death there was no effective, reliable recording of intravenous fluids administered to patients in the emergency department”

“Despite the 8 month interval between Mr [name redacted] death and the Inquest the issues of concern had not been brought to the attention of hospital authorities”

“On arrival at the ED a triage nurse summarised the communication from the urgent care centre. The triage nurse missed important points during the transcription. The attending doctor did not concern himself to look at the communication himself”

“I was concerned that the treating doctor made a contemporaneous note on the 9th July 2022 at Mr [name redacted] first presentation which failed to record the major presenting symptom, diarrhoea with faecal incontinence, which Mr [name redacted] had communicated to the urgent care doctor who in turn had included that in her notes and letter to the ED. The treating doctor did record a flatly contradictory note to the effect there was no change in bowel habit”

“The Incident Investigation Report which is in part designed to assist with learning from adverse events was of a generally poor standard. There was a failure to consider issues in detail; there was a failure to challenge the statements of clinicians where there were obvious contradictions between statements made and the medical record; there was a failure to put in place measures to correct and monitor prescribing clinicians failure to sign off on IV fluid prescriptions so that the contemporaneous”

“The only record in the case was a typed note by a junior doctor to the effect that it was thought Mr [name redacted] had received 2 litres of fluid since arrival”