William Bartram
6 Jun 2018 · Coroner Nadia Persaud · London (East)
The coroner's concerns
1. advice to attend outpatients for repeat bloods
“The Trust's investigation report noted that on the 2 March 2017, the parents should not have been advised to attend outpatients for repeat bloods. They should have been advised to return to the emergency department.”
2. abnormal results missed
“A grossly raised creatinine was found on a capillary blood gas sample taken in A&E on 2 March 2017. It was not noted by the clinical staff. It does not appear that the print out from the machine highlighted the result in any way.”
3. lack of clear advice to parents
“Mr a ci not receive clear advice as to what to look out for, in terms of a he althy urine stream. Advice to parents on the discharge of babies from hospital, would be helpful.”
Responses
No published response was found on judiciary.uk.