Amy Allan
30 Sept 2019 · Coroner Edwin Buckett · London Inner (North)
The coroner's concerns
1. lack of awareness and sharing of information between departments
“It appears there was a lack of awareness and sharing of information between departments at Great Ormond Street Hospital. In particular, the PICU had not been given any advance warning of [the deceased]'s complex medical background and needs before she was admitted there post operation. As PICU staff were not invited to the Multi-Disciplinary Team meetings prior to the operation, they were not aware of the "critical time" which lay ahead for her”
2. no clear plan or instruction for management of Amy post operation
“There was no clear plan or instruction for the management of [the deceased] post operation in relation to extubation and ECMO support on the PICU”
3. poorly executed handover between clinicians
“The handover between clinicians involved in [the deceased]'s operation and those taking over her care in the PICU, was poorly executed with vital information either not properly conveyed or recorded or simply missed”
4. delay in commencing ECMO support
“There was a delay in commencing ECMO support”
5. lack of single properly informed clinician coordinating post-operative care
“No single properly informed clinician appeared to be co-ordinating [the deceased]'s post-operative care in such a complex and high risk case”