Jane Wadsworth
17 Jul 2023 · Coroner Alison Mutch · Manchester South
The coroner's concerns
1. missed antibiotic doses
“Mrs [name redacted] missed three doses of antibiotics prescribed to treat her infection according to the evidence given to the inquest. This did not appear to have been escalated and there was no clear explanation regarding this occurring other than that her cannula may not have been in place and there was a delay in a doctor being available to reinsert one”
2. lack of consultant input
“The evidence before the inquest was that on her admission over Christmas/New Year there was no effective consultant input into her care”
3. lack of doctor to doctor discussion about ICU involvement
“The junior doctor involved in her care felt that ICU involvement/input would be beneficial. The evidence was that there did not seem to be any doctor to doctor discussion of this”
4. inappropriate referral pathway to ICU
“The alternative support available to ward based staff and possible route into ICU according to the evidence given at inquest was via the Critical Care Outreach team”
5. Critical Care Outreach team unavailable due to staff redeployment
“The inquest heard that on the date of one referral that team was not in any event available to the ward and the nurse who should have undertaken the role had been redeployed elsewhere in the trust and there was no capacity to fill that role”
6. lack of specialist Liver team discussion
“Following her first admission to ICU there was a note that Mrs [name redacted] case should be discussed with a specialist Liver team. There was no evidence available to the inquest that such a discussion had taken place”