Keith Hodson
18 Apr 2023 · Coroner Hugh Bricknell · Herefordshire
The coroner's concerns
1. lack of triage system
“an appropriate Triage System is not always adopted in practice at Accident and Emergency”
2. lack of senior oversight
“appropriate senior oversight does not occur”
3. delayed report sign-off
“5.1. reports are not signed off in a timely fashion by a responsible individual”
4. delayed family communication
“Communication with the next of kin appears not to have occurred in a timely fashion”