Matthew Crowley

1. 1. delay in triage

   “A Rapid Access Treatment Protocol (RATT) was not in operation as a result of a busy A&E department which was short staffed. This resulted in a delay in triage”

2. 2. delay in medical review

   “The patient was not seen by a doctor for 2 hours 20 minutes despite being PAR 5 and requiring therefore an immediate review by a senior doctor”

3. 3. delay in decision making

   “There was a delay in ownership and onward management of the patient which resulted in timely decisions not being made. On call consultants responsible for those decisions were not aware of the patient deteriorating because they did not personally review the patient and were not informed of, or did not secure updated information themselves of how acutely unwell the patient was”

4. 4. delay in transfer decision

   “Despite a vascular site declining to accept the patient until his renal function was optimised and a CT angiogram performed, a delay was caused by enquiries being made whether a second vascular site would accept the patient”

5. 5. lack of transfer notification

   “The ITU of the hospital to which the patient was transferred were not informed of the transfer”

No published response was found on judiciary.uk.