During the course of the evidence it became apparent that the time of deliveryladministration of various drugs was of the utmost importance: The nursing staff had completed the records to say that the drugs had been 'given' . The Ward manager accepted that this simply meant that the drip had been 'put up' and did not confirm that the had actually been delivered into the vein of the patient: The husband of the patient contended that the 'bag' remained full and that he did not see any evidence that its contents were in fact administered to the patient: During resuscitation the staff wished to use a "Gum ~elastic Bougie Airway" but when they looked they found it was not available on the 'crash trolley' _ It transpired that this patient was NEVER notified to the RMO on as should be the case_ drug duty

Theard evidence that she required platelets to be transfused but there was a considerable delay in these being made available because "they are not kept on site" and in any event there is no 'agitator' on site for their preparation: When the husband of the deceased drew to the attention of the staff that the saline infusion appeared not to be 'running' he was told by the nurse to "hold her arm straight" to enable it to do so. He and !, and the Ward manager, felt that this was entirely inappropriate. Despite the fact that this patient was receiving (apparently) i.v. fluids, at no time was a fluid balance chart commenced nor was the patient catheterised: The Ward manager agreed that both of these failings were unacceptable. It was acknowledged early in the patient's passage through the hospital that she would need platelets and Hb support; yet it took over four and a half hours for anything to be done about this.