Jordan Howarth

1. 1. withholding antibiotics without joint discussion

   “whilst there was input into [the deceased]'s care from both the microbiologist and the consultant physician there was not a joint approach to his care and no detailed discussions regarding the decision to withhold antibiotics”

2. 2. lack of documented rationale for ICU admission refusal

   “Critical Care Outreach Practitioner had identified that [the deceased] needed to be moved to ICU urgently. This view had then to be ratified by the ICU Consultant if he was to be accepted into ICU. There was no documentation from the ICU consultant setting out their rationale for not examining [the deceased] at that point and for declining to admit him at that point”

3. 3. failure to refer patients with NEWS2 score 5 to CC Outreach

   “anyone who had a NEWS2 score of 5 and no ceiling of care should be referred to the CC Outreach team. The inquest heard evidence that this was not followed on a number of occasions and the fact it had been missed was not identified by more senior members of the nursing team”

4. 4. absence of multidisciplinary discussion and unclear care continuity

   “no evidence of a multi-disciplinary discussion/approach to assess his position fully and that it was unclear who was responsible for the continuity of his care”

Linked reports