Gordon Hendley

1. 1. delayed specialist consultation for Stevens-Johnson Syndrome

   “Stevens-Johnson Syndrome is a dermatological emergency with a significant mortality rate (perhaps over 10% in a man of [the deceased]'s age and frailty), he was referred with this diagnosis by an experienced GP. While evidence suggests a medical consultant was contacted he did not see [the deceased] himself and I heard no evidence to suggest a dermatologist was consulted for advice. Also the SCORTEN or ABCD-10 prognostic tools were not used, they may have been helpful.”

2. 2. delayed escalation of critical test results

   “When [the deceased] returned to A&E late on 20th January there was an excessive delay in his assessment. His blood test revealed a significant lactic acidosis with marked anaemia and very low white blood counts. The A&E consultant who gave evidence said she would have expected this to be escalated to her -she was on call at home, but it was not. I have inputted the data in medical records to the scoring tools referred to above and mortality predictions have now risen to around 50%.”

3. 3. delayed medical review after CT scan

   “[the deceased] had a CT scan, he was referred to medicine but not seen by a medical consultant until 4.30 pm, he was to be admitted to a ward (this happened at 6.30pm) but there is no record in the notes of the significance of the earlier blood test being appreciated.”

4. 4. lack of documented intentional rounding

   “At the inquest into the death of [name redacted] (who died in the A&E department) which I heard last September I was assured that a system of "Intentional Rounding" would take place in A&E when a senior doctor and nurse would go round the department to look at patients & assure themselves that appropriate actions were in hand (I am aware the design of the department is less than ideal). The consultant gave evidence assuring me that this did take place but there were no notes to confirm this”

5. 5. inadequate response to deteriorating physiological observations

   “On the medical ward there still seems to be no sense of urgency in [the deceased]'s treatment. A further blood test at 8.45pm showed severe lactic acidosis and hyperkalaemia but no action seems to have been taken. It was not until the ICU doctor happened upon [the deceased] just before 11pm, 24 hours after he arrived in the hospital that positive steps were taken.”

6. 6. absence of patient advocate in emergency care

   “[the deceased]'s wife was not permitted to be with him in A&E due to Covid restrictions. Thus he had no advocate. I have no doubt that had she been there to speak for him care would have been expedited. It is my view that regardless of policy severely ill patients will benefit from support in similar circumstances.”

No published response was found on judiciary.uk.