Margaret Walker
25 Mar 2014 · Coroner Jennifer Leeming · Manchester (West)
The coroner's concerns
1. lack of medication and blood test result information
“Following Mrs [name redacted] admission to the Sephton Unit at Leigh Infirmary as a detained patient on 4th March 2012, details of her previous medication regime for her diabetes were not sought until the 6th August 2012. When these details were obtained on the 6th August 2012, information concerning the medication was passed to relevant clinical staff but information concerning what blood test results were acceptable for her was not so passed.”
2. inadequate clinical note recording
“Information concerning Mrs [name redacted] medical condition and blood test readings was not appropriately recorded in her clinical notes.”
3. defibrillator not applied before ambulance arrival
“When Mrs [name redacted] was found unresponsive at approximately 6.00am on the morning of the 7th August 2012, cardio-pulmonary resuscitation was appropriately commenced and continued and a defibrillator was obtained. However the defibrillator was not applied prior to the arrival of ambulance personnel who then applied their own defibrillator, which did not reveal a heart rhythm suitable for a shock to be given.”