UK Inquiry Tracker

Hunter Macmillan

PFD Report Historic (No Identified Response) Ref: 2016-0375

Date of Report 24 October 2016

Coroner Chinyere Inyama

Coroner Area London (West)

Response Deadline est. 19 December 2016

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

Emergency Department staffing levels were inadequate, preventing the implementation of national and local policies for the timely and effective treatment of suspected sepsis.

View full coroner's concerns

_ Staffing levels in the Emergency Department were not sufficient to be able to follow national (currently NICE Guideline, Sepsis:recognition, diagnosis and early management) or any local policy on treating suspected sepsis.

Sent To

Chelsea and Westminster Hospitals NHS Trust

Response Status

Linked responses 0 of 1

56-Day Deadline 19 Dec 2016

About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Report Sections

Investigation and Inquest

On 20th of November 2015 commenced an investigation into the death of Hunter Jack Macmillan: The investigation concluded at the end of the inquest on 5"h September 2016 with a narrative_

Circumstances of the Death

Hunter Jack Macmillan was booked into the Urgent Care Centre at West Middlesex Hospital before; as a result of his condition; being taken to the Emergency Department at West Middlesex Hospital. He was not triaged in the Emergency Department for over 45 minutes by which time his condition had deteriorated:

Action Should Be Taken

In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action