Rosemary Scott

5 Jun 2018 · Coroner Brendan Allen · Dorset

The coroner's concerns

1. lack of reminder system for venous blood gas measurement
“During the inquest evidence was heard that: i. Venous blood gases were not measured on the second admission (25”
2. insufficient number of PEEP machines
“The insufficient number of machines to provide PEEP to patients who require it”