Sari Keen
16 Apr 2014 · Coroner Tom Osborne · Bedfordshire & Luton
The coroner's concerns
1. insufficient staffing to manage patient caseload
“three witnesses who gave evidence, two Senior Nurses and one Doctor, told me that on the night that [name redacted] died there were insufficient members of staff available to deal with the caseload of patients and this was not unusual”
2. lack of awareness of un-recordable blood pressure as medical emergency
“many Senior and Junior Members of Staff were not aware that an 'un-recordable blood pressure' was a 'medical emergency' and should have resulted in a crash call going out for immediate resuscitation”