Pamela Moran
12 Nov 2019 · Coroner Aled Gruffydd · Swansea Neath & Port Talbot
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. missed CT scan opportunities
“There were 3 missed opportunities for a CT scan to be undertaken in this case, which may have prevented the deceased's death, or at the very least improved her prospects of survival.”
2. lack of documentation of conversation discrepancy
“There appeared to be no documentation relating to the discrepancy between the accounts of Drs In respect of their conversation on the 14!" of March 2077”
3. no overnight CT scan authorisation
“There does not appear to be a facility for an overnight consultant to authorise a next day CT scan, and relies on a junior doctor to hand over the task at the end of their shift.”
Linked reports
Closely relatedConfidence 0.80 · moderate
This report
“There does not appear to be a facility for an overnight consultant to authorise a next day CT scan, and relies on a junior doctor to hand over the task at the end of their shift.”
Later report
“Two Associate Medical Directors have communicated that delays in undertaking staging scans are ongoing and are having an impact on survivability rates and prognoses by making treatable cancers irresectable.”
Responses
No published response was found on judiciary.uk.