During_the course of the_inquest the evidence revealed mattersgiving_rise to concern_In my opinion City 22nd The The there is a risk that future deaths will occur unless action is taken: In the circumstances it is statutory duty to report to you. my _ in being seen both by Nursing Staff and Doctors in A & E. in being seen by Surgical Team after referral to them at 05.30 hours on the July 2013. in ongoing assessment by the Surgical Team when he started to deteriorate and no Surgical Team member was available to respond to the calls for help from the Nursing Staff at the Acute Medical Unit: (2) No early senior review.

(3) Inappropriate transfer to an Acute Medical Unit when he should either have stayed in A & E or gone to a Surgical Unit: The concern was that he was effectively unsafe and in an inappropriate clinical environment (4) Shere wasea failure t0 appreciate his deterioration largely because he was not seen by the Surgical Team in spite of requests that he should be seen: (5) Even though his acute abdomen had been diagnosed at 07.00 hours there was a failure to appreciate the dangers of his condition.

(6) His clinical management was suboptimal. There was & completely inadequate Ward Round Note made at the hurried ward round between 08.30 and 08.40 hours_ This left the Nursing Staff in the Acute Medical Unit unable to look after this surgical patient efficiently: (8) Failure to prepare Mr: Palmer for surgery which it had been acknowledged he needed urgently (9) Failure to arrange an emergency theatre for him (CEPOD): (10) A complete failure of the CT scanning service at this Hospital. This led Mr. Palmer to be denied a CT scan which would certainly have diagnosed his condition. This failure arose because