Thomas Smith

1. 1. inadequate handover between primary and secondary care

   “No criticism is made of the actions of the Out of Hours Doctor . The inquest however revealed the importance of full and accurate handover between primary and secondary care providers. Such handovers should record full observations and details of any medication already given (for instance painkillers may mask fever). Can the clinical director confirm OOH doctors observe this practice.”

2. 2. delayed pediatric assessment

   “The Coroner noted that it was only by chance that [the deceased] was seen more quickly than usual (because the case was”

3. 3. delayed ambulance transfer for pediatric patient

   “The Coroner would ask that the OOH service notes the concern expressed below that [the deceased] should have been transferred to hospital by ambulance.”

4. 4. conflicting meningitis antibiotic guidance

   “The Coroner notes the guidance at page 61 of the June 2010 publication”

5. 5. snapshot vital sign monitoring

   “The inquest revealed the importance of observing physiological trends in the patient's condition, rather than observing readings on a”

6. 6. nursing concerns ignored by doctors

   “The inquest revealed a somewhat fragmented approach to patient care, with nursing staff concerns not being acted on promptly by doctors. One expert highlighted the importance of a”

No published response was found on judiciary.uk.