Celia Sanderson
10 Feb 2023 · Coroner Alison Mutch · Manchester South
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. delayed clinician review
“Demands on the Emergency Department due to the volume of people waiting to be seen meant that Mrs [name redacted] had a long wait for a clinician review far outside the expected target time”
2. staffing shortage
“shortage of ED consultants and ED middle grade doctors”
3. delayed trauma transfer
“timely transfer to a trauma unit was likely to significantly improve the outcome for a trauma patient”
4. slow CT reporting
“the ability to carry out and report promptly on CT scans was essential if trauma cases were to be identified with sufficient speed”
5. missed silver trauma identification
“potential silver trauma case and ensured she was moved to a trauma centre for appropriate treatment before she began to deteriorate”
6. lack of awareness of silver trauma protocols
“steps taken to increase awareness amongst DGH ED staff to pick up these potential silver trauma cases on arrival”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“The inquest heard that there was a shortage of ED consultants across the NHS which led to these challenges in relation to staffing ED”
This report
“The inquest heard that amongst the challenges faced was a shortage of ED consultants and ED middle grade doctors.”