Timothy Mason

26 Oct 2018 · Coroner Roger Hatch · Kent (North-West)

The coroner's concerns

1. failure to diagnose and treat sepsis
“The reasons for the failure to correctly diagnose and treat [the deceased] on the 16 March 2018 at 03.30. What staff instructions were given to the doctors and nurses in the Emergency Department at the hospital for dealing with patients with symptoms suggestive of sepsis and what tests should have been carried out and why they were not done.”
2. premature discharge of unwell patient
“Why was [the deceased] discharged home on the morning of the 16 March 2018 when he was clearly very unwell and tests had not been carried out.”
3. recurrence of similar incident
“What steps have been taken by the Trust to avoid this situation happening again to another patient in the future.”
4. inadequate staff training
“What training is being given to the doctors and nurses to avoid this situation in the future.”
5. lack of Men ACWY vaccination
“How it happened that [the deceased] did not receive the Men ACWY vaccination and what systems are in place to ensure patients do receive the vaccination, how this is provided and monitored by NHS England and whether this is adequate or should be improved to avoid patients failing to receive the vaccine.”

Stated action

“the practice has now switched on the necessary alerts prompting the offer for patients who have not received the Men ACWY vaccination.”