Julie Robertson

1. 1. lack of blood fridge on ward

   “The possible need for blood had been anticipated as early as 4:40am. If there had been a blood fridge on the ward then the matched blood could have been brought to the ward so that when a transfusion was called for it would have been instantly available on the ward. The blood eventually arrived at 6.55am by which time Mrs [name redacted] was unfit for surgery.”

2. 2. poor record keeping

   “Record keeping was poor and this was acknowledged in the Root Cause Analysis report. Although I heard evidence that there had been some training instigated there is no formal training and indeed witnesses at the inquest still seemed unaware of good practice as to record keeping.”

No published response was found on judiciary.uk.