Ernest Bacon

“when Mr [name redacted] became unwell on 16th January the Trust was staffed at weekend/OOH doctor numbers”

“the staffing numbers of doctors and reliance on junior doctors at weekend to cover the wards is part of the national staffing model”

“he was not placed on the Sepsis pathway and a further review did not take place until a further doctor was asked to examine him at about 22.30 despite his NEWS2 score continuing to trigger for Sepsis”

“The nursing team recognised that he was triggering for Sepsis but the notes were not flagged and the failure to follow the Sepsis policy was not escalated in accordance with Trust Policy”