Claire Twinn
16 Oct 2023 · Coroner Graeme Irvine · East London
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. sub-optimal care due to disability
“Ms [name redacted] disability played a role in the provision of sub-optimal care, reasonable adjustment was not made for; her inability to communicate clearly and her impaired respiratory function when arriving at clinical decisions.”
2. discharge without monitoring and safety-netting
“Neither the trust decision to discharge Ms [name redacted] and not admit for continued monitoring of oxygen levels and remedial oxygen therapy, nor clear safety-netting advice to carers was recorded in the clinical record.”
3. delayed radiological reporting
“A radiological report of the chest x-ray taken on 15th December 2023 was not reported until 25th December 2023.”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“(1) There was a delay of 5 days in the formal reporting of the original X-ray;”
This report
“A radiological report of the chest x-ray taken on 15th December 2023 was not reported until 25th December 2023.”