Evelyn Smith
12 Sept 2014 · Coroner R Brittain · Warwickshire
The coroner's concerns
1. inaccurate and inconsistent recording of vital signs
“The care provided to Miss [name redacted] was reviewed by an independent paediatrician and 4 General Practitioner. | heard evidence that the accurate and consistent recording of Miss [name redacted] vital signs may have allowed earlier recognition of the severity of her illness. | also' heard that the use of the Paediatric Early Warning Scoring system in General Practice may be a useful way of documenting this information. However, it was clear that information in this form is not easy to enter into GP medical”
2. lack of awareness of croup severity scoring system
“From the evidence heard at Miss [name redacted] inquest it was apparent that the scoring system for croup severity was not widely known amongst the clinicians involved in her care. However, her GP did learn of this scoring system after reviewing the 'clinical mentor' tool through the practice's computer software. | heard evidence that systems are in place to prompt entry of certain clinical parameters in specific scenarios; predominantly chronic disease review consultations, such as for diabetes and ast”
Responses
Smith-2014-0406a.pdf ↗· Health Education England