Whilst the hospital sought a review of procedures and protocols the matter was not elevated to a serious untoward incident or root cause analysis where all matters including clinical and nursing decisions were reviewed and subjected to critical examination:
2. Despite the recognition that a consultant-led out of on-call rota is required for patients having undergone surgery_no such rota is yet in place 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Friday 10 June 2016]. |, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION have sent a copy of my report to the Chief Coroner and to following Interested Persons: ((sister of the deceased) Healthcare Governance Manager Patient Safety, RSUH am also under a duty to send Chief Coroner a copy of your response: The Chief Coroner may publish either or both in a complete or redacted or summary form: He may send a copy of this report to any person who he believes may find it useful or of interest: You may make representations to me, the coroner, at time of your response, about the release or the publication of your response by the Chief Coroner: e/oa/zol6 and hours the the the