Martha Davies
16 Sept 2016 · Coroner Caroline Beasley-Murray · Essex
The coroner's concerns
1. communication failures between shifts and senior staff
“Serious failings in communication between shifts, with senior staff, and at multi- disciplinary meetings”
2. over reliance on agency and junior staff
“Over reliance upon agency staff and on junior staff to make decisions”
3. delayed response to deteriorating state
“Lack of prompt response to the patient's deteriorating state”
4. lack of engagement of ward staff and manager
“Lack of engagement of ward staff and ward manager”
5. documentation failures
“Failings in the documentation”
Responses
No published response was found on judiciary.uk.