Margaret Kinsey
25 Oct 2021 · Coroner Alison Mutch · Greater Manchester South
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of senior medical supervision
“The inquest heard that due to the time of her arrival in the Emergency Department on 11th December 2020 consultants were not on site. The most senior doctors available were middle grade and the number available at that time of night was significantly reduced. As a consequence the evidence was that supervision and support of junior doctors was very difficult given the demands on the middle grade doctors on site. This was exacerbated by the fact that on the evening Mrs [name redacted] was admitted the FY doctors”
2. shortage of emergency department consultants
“The inquest heard that there was a shortage of ED consultants across the NHS which led to these challenges in relation to staffing ED and that it was not uncommon for staffing of ED to be based on there being no on site consultant cover in ED from late evening until the morning.”
3. inconsistent documentation of clinical discussions
“The inquest heard that there was no standard approach as to how the details of information shared/discussions between clinicians should be detailed or signed off in the notes when one clinician was acting in a supervisory capacity. Given the regular movement of junior doctors across the NHS this meant documentation quality was inconsistent.”
Linked reports
Closely relatedConfidence 0.86 · high
Earlier report
“| am concerned about the lack of appropriate clinical supervision and guidance for junior medical staff. Two junior doctors were asked to attend the ward and made no appropriate clinical records of the reason for their attendance, reviewing the records, seeing the patient and explaining any clinical decision to prescribe medication.”
This report
“The inquest heard that due to the time of her arrival in the Emergency Department on 11th December 2020 consultants were not on site. The most senior doctors available were middle grade and the number available at that time of night was significantly reduced.”
Closely relatedConfidence 0.90 · high
This report
“The inquest heard that there was a shortage of ED consultants across the NHS which led to these challenges in relation to staffing ED”
Later report
“The inquest heard that amongst the challenges faced was a shortage of ED consultants and ED middle grade doctors.”
Responses
No published response was found on judiciary.uk.