Mary Forlin

“clinicians did not actively consider or appear to follow the guidance, despite blood tests showing continuing signs of infection which broad spectrum antibiotics had not reduced. Nor were microbiology tests ordered early on when antibiotics had had no immediate effect”

“current policies, systems and processes - including electronic records - do not proactively flag, up, drive or require active consideration of tests, including whether and when results have been obtained, or whether further specialist tests should then be required”

“risk of further deaths, and that further action should be taken to reduce the risk of death in such circumstances”