Princess Royal Hospital in Haywards Heath for further rehabilitation and to be closer to one of her sons address. It was noted that the amount of air reaching the side of her right lung was reduced and a chest XR was ordered. She continued to have chest physiotherapy, saline nebulisers and antibiotics. Between 1-3 April there was a period of stability as noted in the NEWS records and Mrs Stockley was using less pain relief.

However, by 8 April, the breathing difficulties resurfaced and without oxygen her saturation levels dropped but rose again after receiving oxygen. A chest x-ray suggested a raised right hemidiaphragm and some fluid was collecting at the base of both lungs. A specialist respiratory review was conducted during the afternoon of 9 April and concern expressed that the hemidiaphragm may be paralysed. An ultrasound scan was recommended and new targets for maintaining oxygen saturation levels between 88-92% were set to be monitored every 2 hours. Arterial blood gas tests were carried out followed by a further review by the critical care outreach team who did not make any changes to the respiratory registrar's plan. These were repeated again that evening by a junior doctor and he requested the nursing staff to carry out observations throughout the night.

Mrs Stockley was monitored every 2 hours and at 6.35 a.m. her NEWS score was 4 but doubled to 8 by 7.20 due to a raised respiratory and heart rate. Nursing staff contacted the same junior doctor but he did not review Mrs Stockley on the ward. Later the same day her condition deteriorated rapidly and she descended into respiratory failure which required transfer to intensive care for eventual intubation on 10th April. An ultrasound confirmed consolidation and collapse of the right lower lobe with minimal diaphragmatic movement.

Between the 10th April and her eventual death on 20th April efforts were made to wean down her ventilator setting and reduce her sedation to allow her to do more of her own breathing. This did not work as she become agitated and on one occasion tried to remove her tube. Further ventilation was discussed but eventually she was placed on an end of life pathway until she died on 20th April at 02.28.

1. On 9 April, Mrs Stockley's respiratory condition was clearly deteriorating necessitating critical care review who recommended careful and consistent observation of principally her oxygen saturation levels. The NEWS score was a vital tool to alert clinical staff to an acute change yet despite the fact the score went from 4 to 8, the junior doctor did not review the patient. I heard evidence from nursing staff that the doctor felt the patient may simply have been anxious. This suggests a potential training need for doctors and/or nurses.

2. Further, although the nurse quite rightly telephoned a doctor it was far from clear whether the right doctor had been contacted. The national NEWS forms were in use at the time of Mrs Stockley's death to record observations but the policy that governed their use was the 2012 MEWS Escalation Policy and the two policies were different. From evidence heard from both doctors and nurses, it suggests the need to revisit how the NEWS policy is applied locally especially around which doctor should be contacted when there is an acute change.

3. The nurse who had monitored Mrs Stockley throughout the night and contacted the junior doctor when the NEWS score spiked handed over to the day nurse shortly after her conversation with the doctor. From evidence heard at inquest, there may