David Martin

“The inquest heard evidence that the locum SHO involved in the care of Mr [name redacted] was 9 days into a 3-4 month period of cover. She had not received any cardiology induction and was unaware of the Trust DAPT policy regarding PCI patients. It was accepted that while it was a challenge to ensure locums who covered 1-2 shifts had a thorough induction, where one was being asked to work in the service for an extended period of time, it was necessary that there was a proper induction process. The inquest”

“There were multiple opportunities where the fact Mr [name redacted] was receiving Aspirin only was not recognised. This included the completion of a WHO checklist intended to identify issues of this nature. Of greater concern is that a Deputy Sister who completed the cardiac cath lab pack did recognise the oversight but this was still not acted upon by medical colleagues.”