Maria Lopes
11 Jul 2014 · Coroner Karen Henderson · Surrey
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of consultant ward rounds during on-call weekend coverage
“The consultant urologist's on call arrangements covering three hospitals at the weekend has no provision for consultant ward rounds, in contravention of suggested national guidelines”
2. non-implementation of on-call national guidelines
“A general lack of knowledge or implementation of published 'on call' national guidelines”
3. insufficient supervision of out-of-hours urology trainees
“The overall supervision of out of hours urology trainees within the current system”
4. delayed urology review of emergency admissions
“The review of emergency admissions by urology (not on day of admission, once daily)”
5. failure to recognise and treat sepsis per national guidelines
“The recognition and treatment of sepsis as per national guidelines”
6. inadequate assessment of renal stone and reliance on outdated blood tests
“The assessment and size of the renal stone and hydronephrosis, and undue reliance on blood tests taken on admission (18 hours previously) to assess Mrs [name redacted] condition”
Linked reports
Identical hazardConfidence 0.90 · high
This report
“The recognition and treatment of sepsis as per national guidelines”
Later report
“During the evening of 3rd May 2022 going into the early hours of 4th May 2022, Doctors and nurses failed to identify the extent of Mr [name redacted] gastrostomy leak and the onset of sepsis.”
Responses
2014-0325-Response-by-Frimley-Park-Hospital.pdf ↗· Frimley Park Hospital NHS Trust