James Allbones
21 Jul 2017 · Coroner Elizabeth Didcock · Nottinghamshire
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. child not transferred to paediatric intensive care
“a child as ill as [the deceased] will again be moved from the Emergency Department to the ward or Assessment Unit at the Hospital, rather than being transferred out for ongoing care - there is no reassurance that a sick child will be seen by a Consultant [name redacted] in the Emergency Department to assist with this decision”
2. sepsis signs not recognised
“the 'red fiag' signs of sepsis will not be recognized and acted upon by the Paediatric team unless there is further training and awareness raising”
3. no face to face medical handover protocol
“there is still no protocol for face to face medical handover”
4. rejection of safety culture model
“the Consultant team have rejected a model of care that encourages frank discussion with nursing and other staff on the ward, aimed at helping all staff speak up when worried about a deteriorating child (the RCPCH SAFE model)”
5. insufficient paediatric staffing
“the level of Paediatric staffing at Bassetlaw Hospital. | understand there is often only one junior doctor available, and that the middle grade doctor is on duty for 24 hours”
Linked reports
Identical hazardConfidence 0.90 · high
This report
“that there is still no protocol for face to face medical handover”
Later report
“the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers”
Responses
No published response was found on judiciary.uk.