Frances Bell
6 Jun 2014 · Coroner Caroline Beasley-Murray · Essex
The coroner's concerns
1. lack of root cause analysis investigation
“There was no Root Causes Analysis Investigation carried out which would have identified lessons learned and an action plan”
2. lack of senior clinical staff input
“There was no input from senior clinical staff at the time of Mrs [name redacted] presentation on 30 March”
3. unacceptable delay to theatre arrival
“There was an unacceptable delay between Mrs [name redacted] readmission on the 31 March and her arrival in theatre on 1 April”
Responses
No published response was found on judiciary.uk.