Alfie Rose

“1. There was poor communication between both hospitals in relation to [the deceased]'s condition and care. Details of his neurosurgical review on 16/05/16 were not made available to [name redacted]'s Hall Hospital. His clinical condition was not relayed to QE hospital on 27/05/16 or morning of 06/06/16. These were vital missed opportunities to transfer him back to QE for treatment. Both Trusts need to look at their communication systems and identify areas for improvement and to clarify if the NORSE system is”

“Education. It is important the clinicians in outlying hospitals understand how neurological referrals should be made and when. Better guidance and education is needed for outlying hospitals.”