Scott Hooper

1. 1. incorrect weight recording leading to dosing error

   “On admission to SGH on 12 March, Mr [name redacted] weight was incorrectly recorded as 80kg when the reality was his true weight was 107 kg - a difference of 27 kg (4st 3.5Ibs) which is a considerable difference. This is important as the amount of anti-coagulant drugs to be given according to the SGH thromboprophylaxis protocol is calculated on weight”

2. 2. unrecorded clinical decision

   “As stated above, on 15 March when the clinical decision was made to withhold the morning dose of Tpx medication it could not be ascertained who made the decision. This was a significant clinical decision and it is a basic requirement that all clinical decisions are recorded in order to capture capturing who made the decision and why”

3. 3. limited dissemination of lessons

   “a single T2O M&M meeting is only effective for those doctors and nursing staff who attend. | was not given any other detail as to how the valuable lessons to be learned from this case were to be spread to clinical staff across the T&O department or the whole Trust as weight estimation can be equally important in many other medical specialisms”

No published response was found on judiciary.uk.