Stephen Palmer

1. 1. delayed medical assessment

   “Delay in being seen both by Nursing Staff and Doctors in A & E. Delay in being seen by Surgical Team after referral to them at 05:30 hours on the 13" July 2013. Delay in ongoing assessment by the Surgical Team when he started to deteriorate and no Surgical Team member was available to respond to the calls for help from the Nursing Staff at the Acute Medical Unit.”

2. 2. inappropriate clinical environment

   “Inappropriate transfer to an Acute Medical Unit when he should either have stayed in A & E or gone to a Surgical Unit. The concern was that he was effectively unsafe and in an inappropriate clinical environment.”

3. 3. failure to recognize deterioration

   “There was a failure to appreciate his deterioration largely because he was not seen by the Surgical Team in spite of requests that he should be seen.”

4. 4. failure to appreciate condition severity

   “Even though his acute abdomen had been diagnosed at 07:00 hours there was a failure to appreciate the dangers of his condition.”

5. 5. inadequate documentation

   “There was a completely inadequate Ward Round Note made at the hurried ward round between 08:30 and 08:40 hours. This left the Nursing Staff in the Acute Medical Unit unable to look after this surgical patient efficiently.”

No published response was found on judiciary.uk.