Tripta Bhanote
16 Sept 2021 · Coroner Zafar Siddique · Black Country
The coroner's concerns
1. delayed emergency response
“lack of clarity and understanding by care staff in the requirements for escalation to emergency services when a patient/resident becomes acutely unwell”
2. missed referral to quality team
“lack of clarity and understanding by care staff of the role of the enhanced care and quality team and circumstances for referral to them”
3. inadequate DNAR identification
“evidence of poor procedures in place in identifying the DNAR status of residents”
Responses
No published response was found on judiciary.uk.