Brian Colby
26 Jun 2024 · Coroner Ian Potter · Inner North London
The coroner's concerns
1. lack of clear escalation protocols for deteriorating patients
“there did not appear to be any, or any clear, protocol(s) in place for the escalation of a deteriorating patient”
2. ineffective communication via text message for urgent escalation
“the sending of a text message is not likely to be the most effective way of escalating serious (and presumably urgent) concerns about patients”
3. delayed diagnostic imaging for deteriorating patient
“There was a delay in Mr [name redacted] being sent for a scan as a result, albeit there were other delays for different reasons”
4. inconsistent application of resident doctor authority for urgent investigations
“the authority of resident doctors to commence the scan ordering process in advance of a consultant discussion has now been re-emphasised across the Resident Doctor Training Group”