Karen Peters
17 Apr 2014 · Coroner Andrew Cox · Plymouth, Torbay & South Devon
The coroner's concerns
1. Insufficient nursing staffing in Medical Admissions Unit
“Staffing levels in MAU as a whole”
2. Use of agency nurses in high‑acuity roles without sufficient permanent staff
“Deployment of Agency Staff”
3. Inconsistent handover communication about critical neurological observations
“The quality of handover information”
4. Failure to act on deteriorating GCS scores and to arrange CT scan promptly
“Measuring and Recording GCS”
5. Administration of anticoagulant despite contraindication leading to worsened bleeding
“Following [the deceased]'s fall at 14:00 hours, the medical staff should have directed that [the deceased] was not to receive any further anticoagulation medication until staff were satisfied that her neurological status was stable”
6. Lack of airway support during CT scan for a critically ill patient
“At 06.15 hours on 29 March, [the deceased] was found to have a GCS of 6. She was sent for an immediate CT Scan and this was completed within 45 minutes, which I found to be commendable”
Responses
No published response was found on judiciary.uk.