Samantha Beach
21 Oct 2015 · Coroner Katy Skerrett · Gloucestershire
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. inadequate escalation of clinical care
“The clinical care provided to [name redacted] in the obstetric department was not escalated appropriately to more senior colleagues”
2. lack of integrated community care
“When [name redacted] was being cared for in the community, there was no process to ensure the sharing of information or joining up of care between the midwives, out of hours, GP and obstetric department”
3. absence of obstetric involvement in emergency care
“When [name redacted] attended the Emergency Department as a post-natal patient (7 days post partum) the obstetric department were not involved in her care.”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“The clinical care provided to [name redacted] in the obstetric department was not escalated appropriately to more senior colleagues,”
Later report
“Whether there is appropriate escalation of care given to a patient who acutely deteriorates during the night shifts over the weekend period.”
Responses
No published response was found on judiciary.uk.