Nimo Osman
12 Aug 2024 · Coroner Ian Potter · Inner North London
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. delayed emergency ambulance call
“Following the discovery of Ms [name redacted] collapse on Rosebank Ward on 21 April 2022, it took staff a significant number of minutes to recognise that instead of just lying on the floor, Ms [name redacted] was actually unrousable. A few minutes later a nurse arrived on the scene, who decided to summon the duty senior nurse (DSN) by radio, rather than activating the alarm system, which would have summoned the rapid response team sooner. The DSN contacted the duty doctor to inform them that there was a medical emergency”
2. assumption of mental cause over physical cause
“Staff should consider whether patients' behaviour might be due to being physically unwell and not assume that this is due to their mental health condition.”
3. incomplete VTE risk assessment
“As per Physical Healthcare Policy, v.14.1, Feb 2021, 7.6, all patients should have a VTE risk assessment form completed and a VTE assessment on admission to the in-patient unit.”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“At no time during the two periods of Ms [name redacted] inpatient care was she assessed for venous thromboembolism (VTE) risk in contravention of trust policy.”
This report
“As per Physical Healthcare Policy, v.14.1, Feb 2021, 7.6, all patients should have a VTE risk assessment form completed and a VTE assessment on admission to the in-patient unit.”