Jordan Babb
25 Jul 2025 · Coroner Tom Osborne · Milton Keynes
The coroner's concerns
1. abnormal observations not escalated
“Failure to Escalate Abnormal Observations”
2. lack of structured risk assessment for pulmonary embolism
“Lack of Structured Risk Assessment for Pulmonary Embolism”
3. misunderstanding of clinical decision tools
“Unclear Use or Misunderstanding of Clinical Decision Tools”
4. risk of repetition in similar settings
“Risk of Repetition in Similar Settings”