Simon Willans

1. 1. lack of scrutiny of ambulatory care unit following death

   “BCUHB have only just commenced an SIR on this matter and the ambulatory care unit, its structure, practices, systems, staff have not been effectively scrutinised following Mr [name redacted] death in direct contravention of the policy of BCUHB on reporting and given this the following concerns do not appear to have been addressed potentially compromising patient safety until the conclusion of the SIR”

2. 2. absence of consultant documentation in patient notes

   “the Consultant in charge of the unit did not make any entries in any of the notes for Mr [name redacted] . There is no record of him examining the patient, the abnormal test results, the detail of 37 Castle Square, Caernarfon”

3. 3. discharge by unauthorized nurse without patient involvement

   “Mr [name redacted] appears to have been discharged by a Nurse [name redacted] who had no involvement in the care of Mr [name redacted]. , or any other doctor does not appear to have been involved in the discharge of Mr [name redacted]. Nurse [name redacted] adds another diagnosis to the GP letter over and above that of her colleague despite never seeing the patient”

4. 4. lack of safety netting for worsening condition

   “There is insufficient safety netting for this patient. He was not told what to do in the event of a worsening of his condition. The letter to the GP was faxed the day after discharge by which time he had died”

5. 5. inadequate family history collection

   “The history recovered by Nurse [name redacted] is inadequate in that it did not elicit family history of Pulmonary Embolism”

6. 6. failure to initiate anticoagulation therapy

   “Heparin was not commenced even though a DVT /PE was one differential diagnosis”

No published response was found on judiciary.uk.