Margaret Bailey

“On the 'office' receiving a call from a carer reporting, as here, that a client appears to be unwell there is no algorithm for the call handler (who tends to be an assistant manager/manager but with no medical background) to follow to triage the client, setting out why the client appears unwell and to then determine a course of action. The direction of the conversation is simply left to the 'office'”

“There was no ability for the carer reporting that [the deceased] was unwell to carry out any basic observations, neither before the call to the office nor after it, in order that [the deceased] could be monitored as per the advice given or to at least provide a baseline for monitoring, not even a temperature reading”