Samantha Brousas
20 Dec 2019 · Coroner Joanna Lees · North Wales (East and Central)
The coroner's concerns
1. lack of pre-alert for suspected sepsis
“the absence of a pre alert meant that the ED had no opportunity to prepare for [name redacted]'s arrival and there could have then been no doubt as to the severity of her illness or her condition”
2. delayed antibiotic administration for sepsis
“the first line treatment for sepsis was the administration of anti-biotics within an hour of arrival at a hospital”
3. lack of escalation pathway for paramedic concerns
“neither paramedic escalated these concerns either through Ambulance Control or through hospital escalation channels”