There was a lack of clinical observations for a period of 12 hours on the 9th December: In addition no nursing observations were carried out during this period of time_ 2, At 6 am Mrs White's PARS score was recorded as 2 when this should have been 5 which if correctly recorded would have led to medical intervention. There was a shortage of staff on duty on the Surgical Unit on the night of the 9th December: There was only one auxillary nurse who was not familiar with the Surgical Unit: This Unit is one step down from the High Dependency Unit and the patients require a high level of nursing care_ However , there was a lack of escalation of this issue to the Night Nurse Practitioner. There was a lack of information in the patient's medical records following the handover from the staff to the night staff. Following the review of Mrs White on the 9th December when further tests had been requested there was a lack of any further clinical consideration and no escalation to a consultant; At the Inquest heard evidence from Di who was the SHO on during the night and who had received the handover from the day staff. Her evidence was the she had no recollection of Mrs White being mentioned at the handover and was unaware that there were outstanding investigations.