Bonnie Webster
25 Nov 2022 · Coroner Jacqueline Lake · Norfolk
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. lack of clear communication about caesarean section
“The evidence of Mr and Mrs [name redacted] is they were unaware of the seriousness of the situation. Caesarian Section was discussed but was not advised or recommended at the meeting at 06.50 hours. This was clearly a traumatic meeting and Mr and Mrs [name redacted] were upset which would have impacted on their ability to understand and take in important information. In such a situation clear language and ensuring an understanding of the whole situation is paramount”
2. delayed administration of antibiotics
“Antiobiotics were prescribed at the initial review meeting at 09.35 hours. These were not given until 12.30 hours”
3. staff alerted paediatric team via foot instead of emergency system
“Evidence was heard that staff alerted the paediatric team on foot, rather than using the emergency”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“Nurses had difficulty in contacting front line on call medical staff on two occasions.”
This report
“Evidence was heard that staff alerted the paediatric team on foot, rather than using the emergency "bleep" system”
Responses
2022-0378-Response-from-The-Queen-Elizabeth-Hospital-Kings-Lynn.pdf ↗· Queen Elizabeth Hospital
Stated action
“In my role as Acting Chief Executive Officer of The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust I now set out the Trust's responses to the three concerns you raised in box (5) of the report.”