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recurance

Esmee Polmear

27 May 2016 · Coroner Elizabeth Carlyon · Cornwall

The coroner's concerns

  1. 1. lack of routine respiratory rate bench-markers in paediatric respiratory medicine

    “The routine use of respiratory rate bench-markers in paediatric respiratory medicine”
  2. 2. lack of routine oxygen blood monitoring in paediatric medicine

    “The use of routine oxygen blood monitoring in paediatric medicine”
  3. 3. failure to recognise and act on red flag markers

    “The recognition and action on red flag markers (which in this case were shortness of breath, chest pain and blue lips)”

Responses

No published response was found on judiciary.uk.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error