Delayed Recognition of Deterioration
407 items
2 sources
Failure to timely recognize, report, and escalate deteriorating patient conditions, leading to delayed intervention.
Cross-Source Insight
Delayed Recognition of Deterioration has been flagged across 2 independent accountability sources:
6 inquiry recs
401 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (6)
IBI-6a(i) — Hepatologist Oversight and Fibroscan Access
Recommendation: All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Those who have been diagnosed with cirrhosis at any point should receive lifetime monitoring by way of six-monthly fibroscans and annual clinical …
Gov response: UK Government We accept this recommendation but will balance its implementation against NHS England’s role to promote equitable access for all, the principle that patients should receive the same treatment irrespective of how the disease …
Accepted
In progress
IBI-6a(ii) — Specialist Hepatology Centre Access
Recommendation: All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Those who have fibrosis should receive the same care
Gov response: UK Government We accept this recommendation but will balance its implementation against NHS England’s role to promote equitable access for all, the principle that patients should receive the same treatment irrespective of how the disease …
Accepted in Part
In progress
IBI-6a(iii) — Fibroscan Every Six Months
Recommendation: All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Where there is any uncertainty about whether a patient has fibrosis they should receive the same care
Gov response: UK Government We accept this recommendation but will balance its implementation against NHS England’s role to promote equitable access for all, the principle that patients should receive the same treatment irrespective of how the disease …
Accepted
In progress
IBI-6a(iv) — Named Hepatology Nurse Specialist
Recommendation: All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Fibroscan [ultrasound] technology should be used for liver imaging, rather than alternatives
Gov response: UK Government We accept this recommendation but will balance its implementation against NHS England’s role to promote equitable access for all, the principle that patients should receive the same treatment irrespective of how the disease …
Accepted
In progress
IBI-6a(v) — Annual GP Appointment for Co-morbidities
Recommendation: All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Those who have had Hepatitis C which is attributable to infected blood or blood products should be seen by a consultant hepatologist, …
Gov response: UK Government We accept this recommendation but will balance its implementation against NHS England’s role to promote equitable access for all, the principle that patients should receive the same treatment irrespective of how the disease …
Accepted in Part
In progress
IBI-6a(vi) — Assessment for Hepatocellular Carcinoma
Recommendation: All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Those bodies responsible for commissioning hepatology services in each of the home nations should publish the steps they have taken to satisfy …
Gov response: UK Government We accept this recommendation but will balance its implementation against NHS England’s role to promote equitable access for all, the principle that patients should receive the same treatment irrespective of how the disease …
Accepted
In progress
PFD Reports (401) — showing 100 most recent
Geoffrey Gudgeon
Concerns: There is a significant capacity issue in Cornwall concerning the timely admission and treatment of stroke patients, leading to delays in accessing stroke units.
Response: The Trust has implemented a Stroke Bed Escalation Plan, increased Stroke Consultant availability, and rapid data reviews, which have led to improved admission times and inpatient stay percentages for stroke …
Responded
Edward Jones
Concerns: There is no nationally validated sepsis screening tool for Paediatric Emergency Departments, and the trust's own tool lacks consistent application between departments.
Pending
Roger Smith
Concerns: Ineffective electronic patient records failed to flag critical medication information, and poor communication led to anticoagulation being administered against patient wishes, without specialist stroke input.
Pending
Della Calvey
Concerns: Unsafe practice of routinely downgrading NEWS scores for all COPD patients without knowing individual baseline saturations leads to inadequate clinical assessments.
Pending
Debapriya Ghosh and David Ward
Concerns: Insufficient staffing and bed spaces in A&E resulted in frail elderly patients being unsupervised, leading to unwitnessed falls, fatal head injuries, and a failure to provide necessary enhanced nursing care.
Response: The Department for Health and Social Care acknowledges A&E staffing and demand concerns, highlighting actions already implemented by St George’s Trust. DHSC's own response outlines a 2025/26 Urgent and Emergency …
Responded
Paolino Amico
Concerns: Multiple serious medication errors, including non-administration of pain relief and prescription mistakes, occurred. There were also critical failures in the discharge plan for oxygen and delays in escalating a deteriorating patient's condition.
Response: NHS England highlights its ongoing work to improve patient safety, detailing how its Patient Safety Group has strengthened leadership, monitors medicines safety and patient deterioration, and ensures timely incident closure …
Response: The Trust has implemented a new comprehensive discharge checklist for all patients and made medical gases training mandatory for staff. They have also introduced a mandatory 'Essential Training' module for …
Responded
Thomas Morrell
Concerns: Failure to promptly recognise heart failure and the absence of a HOCM patient referral SOP delayed specialist transfer. A lack of regular cardiac monitoring also meant deterioration was missed, losing intervention opportunities.
Response: York Scarborough Hospital circulated a message to relevant clinicians regarding the importance of timely referral to a transplant centre. However, the Trust maintains that Mr Morrell’s overall management was appropriate, …
Responded
Barry Loxston
Concerns: Serious failures pre-surgery included not recognising unfitness for transplant. Post-operatively, critically low potassium was untreated due to workload, and nursing care lacked proper manual handling and timely response to basic needs, causing distress.
Overdue
Tracey Oldfield
Concerns: Delayed prescription of usual medications for late-admitted patients leads to inappropriate alternative pain relief. The process for timely medication prescription for such patients is unclear and unresolved.
Response: Royal Cornwall Hospital has established a multidisciplinary group to strengthen governance for timely prescribing of medications for unexpectedly admitted day-case patients. They have identified four workstreams, including ensuring systems alert …
Responded
Joan Talbot
Concerns: Due to a lack of continuity across different admitting teams, the significance of a patient's repeated symptoms was not fully appreciated, delaying necessary investigation.
Response: Kings College Hospital NHS Trust has established a cross-Trust 'Documentation Quality Improvement Working Group' to improve the use of their EPIC record system. This group will define metrics, identify barriers …
Responded
Richard Worswick
Concerns: Unclear wound care instructions on hospital discharge and a lack of documented communication between the hospital and care home led to confusion. The care home also lacked an escalation policy for such unclear care plans.
Response: Bamford Grange Care Home has issued refresher guidance on existing policies for re-admission and wound care monitoring, ensuring all calls to external teams are documented (including unsuccessful ones with mitigation …
Response: Stockport NHS Foundation Trust has issued a Trust-wide alert (20 November 2025) requiring two copies of Transfer of Care documentation to be printed: one for the patient and one for …
Responded
Ernest Gray
Concerns: The hospital failed to involve the patient's primary carer in discharge planning and neglected to provide holistic information about his fluctuating delirium, including potential aggression, leaving carers unprepared for his complex needs.
Response: East Kent Hospitals has updated their discharge checklist to ensure identification of main carers, developed a care advice leaflet for patients with carers, and implemented a 'carer's passport' and a …
Responded
Judith Hughes
Concerns: The hospital's fall risk assessment tool is confusing due to unclear factor definitions, risking incorrect scores, insufficient observation levels, and increased patient falls.
Response: The Trust's 'Enhanced Care Risk Assessment Form' was revised in 2022 to clarify the distinction between 'previous falls in the last 12 months' and 'inpatient fall during this admission'. Nursing …
Responded
Lynn Silcock
Concerns: A patient was discharged by gastroenterology without cardiology consultation or follow-up, due to a lack of communication and document exchange between teams, leading them to be "forgotten" and without trust investigation.
Response: NHS England states the specific issues raised fall outside its direct role and remit, primarily resting with Shrewsbury and Telford Hospital NHS Trust (SATH). It notes its existing national Frontline …
Response: The Trust has initiated a Patient Safety Investigation (PSII), completed a review of discharge processes in Gastroenterology with Cardiology input, and created a new policy for referrals. A single referral …
Responded
Amy Cross
Concerns: There is no system to ensure vital healthcare information, including medication and observations, is shared between criminal justice healthcare providers, and no standard, accessible medical records system.
Response: NHS England plans to commence a 'proof of concept' trial around February/March 2026 in specific regions, enabling healthcare providers to access the Digital Person Escort Record (DPER) system to improve …
Overdue
Amanda Wood
Concerns: No sepsis screen was performed before discharge from the Emergency Department, indicating a failure in early identification and treatment of sepsis.
Overdue
Pamela Singh
Concerns: There is a lack of specific practice tools for family and care staff to recognise and escalate acute health deterioration in people with learning disabilities, despite national recommendations for such tools.
Responded
Audrey Newman
Concerns: A lack of trained ward doctors for lumbar punctures and the absence of a formal escalation pathway for assistance created significant delays in crucial diagnostic testing.
Overdue
Emily Hewerdine
Concerns: Patients faced inadequate hydration assessments and fluid charting, nursing failures to identify deterioration, and a lack of clinical assessment in the Emergency Department before mental health referrals or discharge.
Overdue
Suzanne Edwards
Concerns: Emergency Departments lack reliable access to patients' primary care records, leading to delayed or misdirected diagnoses and undermining patient safety due to incomplete medical history.
Overdue
Joanne Stones
Concerns: The hospital failed to prioritise a seriously ill patient, overlooking critical medical alerts and existing diagnoses, and neglected to consult specialists, leading to significant delays and inappropriate treatment.
Responded
Jordan Babb
Concerns: Failures in a walk-in centre to escalate abnormal vital signs, conduct structured risk assessments for pulmonary embolism, and properly apply clinical decision tools indicate a lack of clear protocols and training.
Overdue
Doreen Swann
Concerns: Persistent delayed hospital discharges due to social care bed shortages force high-falls-risk patients to remain in acute settings, straining resources and potentially compromising patient safety and bed availability.
Responded
Jason Clemens
Concerns: The hospital lacked clear standard operating procedures and defined pathways for deteriorating renal patients, causing treatment delays and medication errors, despite similar concerns in a previous report.
Responded
Brenda Fisher
Concerns: Keeping patients for prolonged periods in unsuitable Emergency Department corridors, not designed for continuous care and observations, presents an inherent and residual risk of death.
Responded
Charlotte Alderson
Concerns: Inconsistent infection scoring systems, a lack of rapid sepsis identification tools, and failures in the 111/999 information handover system risk critical delays and errors in patient care.
Responded
Mark Villers
Concerns: Insufficient radiologists led to a critical abnormality (aortic dissection) being missed on a CT scan, with current staffing levels still below guidelines, posing a risk of future deaths.
Responded
Abdirahman Afrah
Concerns: A&E had excessive waiting times and lacked timely medical triage, risking critical patient deterioration. Follow-up calls were made without full clinical information or clear advice, and essential patient results were not sent to the GP due to staff unfamiliarity with the process.
Responded
Keith Inseon
Concerns: Care home record-keeping was inaccurate and incomplete, as observation scores after a fall were not consistently recorded, hindering proper assessment for escalation to medical services. The system remains unaddressed.
Responded
Sarah Hill
Concerns: Inadequate falls risk assessments, poor documentation, and infrequent observations for a deteriorating patient were compounded by unsafe side-room placement and severe understaffing.
Responded
Ian Simpson
Concerns: The care home delayed calling an ambulance for an unresponsive resident and maintained inadequate, inaccurate records, including misleading and unlabelled retrospective entries, compromising patient safety.
Responded
Raihana Oluwadamilola Awolaja
Concerns: A child requiring 1:1 tracheostomy care died due to inadequate supervision and insufficient staffing, leading to a blocked tracheostomy. This represents a gross failure in care.
Responded
Marina Raisbeck
Concerns: No systems exist for prioritizing or monitoring the clinical parameters of urgent surgical patients awaiting transfer between emergency departments and receiving hospitals.
Responded
Jack Shields
Concerns: An ambulance crew failed to recognise a patient's critical deterioration into cardiogenic shock and incorrectly prioritised their backup request, resulting in a prolonged delay to definitive medical care.
Responded
Lachlan Campbell
Concerns: Critical ambulance response delays, caused by extensive hospital handover times, prevented timely conveyance of a patient to hospital, which an expert stated would have prevented their death.
Responded
Philip Unwin
Concerns: Medical teams failed to timely escalate care for a deteriorating patient, and the Emergency Department resuscitation area remains understaffed, not complying with national guidance for patient-to-nurse ratios.
Responded
Carl Eastman
Concerns: There were significant delays in conducting critical CT scans, widespread communication failures, poor record-keeping, and a lack of professional curiosity among staff, indicating potential skills deficits.
Responded
Terence Grainger
Concerns: Lack of electronic patient observation systems poses a risk due to potential manual recording errors, miscalculation of NEWS 2 scores, and inability to track patient deterioration trends.
Responded
Carla Smith
Concerns: Excessively long hospital waiting lists for urgent and routine referrals, coupled with a lack of patient monitoring, risk significant deterioration and loss of treatment options.
Responded
REDACTED
Concerns: Student accommodation staff caused significant delays in initiating and physically conducting a welfare check, and showed reluctance to fully enter the room, prolonging emergency response for a distressed student.
Responded
Jackson Yeow
Concerns: Routine corridor care in the emergency department impedes clinical assessment, delays ambulance handovers, and normalizes unsafe practices due to significant delays in discharging medically fit patients.
Responded
Michael Jervis
Concerns: Despite repeated observations indicating sepsis and a need for antibiotics, the sepsis six protocol was not triggered due to staff failure and the absence of a digital alert system.
Responded
David Lodge
Concerns: The emergency department failed to accurately assess pain in a non-verbal patient, conduct basic examinations for pneumonia, and appropriately escalate high NEWS2 scores, coupled with a lack of internal incident review.
Responded
Eleanor Aldred-Owen
Concerns: The hospital's standard operating procedure for radiographers lacked provisions for escalating care or initiating urgent arrest calls when patients showed clear signs of imminent danger.
Responded
Laura-Jane Seaman
Concerns: Critical failures in medical record-keeping, delayed patient escalation, non-compliance with major haemorrhage protocols, and misidentification of maternal collapse contributed to the death, highlighting training deficiencies in covert bleeding.
Responded
Thomas Burroughs
Concerns: A split Hickman Catheter, posing a significant infection risk, was not removed promptly despite advice and was not reported via the Trust's Datix system as required by protocol.
Responded
Peter Parker
Concerns: Significant ambulance response delays, exceeding the expected survivability of severe injuries, were caused by ambulances being held up at Emergency Departments, preventing them from attending new calls.
Responded
Henry Willems
Concerns: Ambulance service failed to meet Category 2 response times by over two hours due to extreme surge levels and significant vehicle delays at hospitals, likely leading to the deceased's preventable death.
Responded
Stephen Stringer
Concerns: A GP practice's electronic enquiry system critically failed to log patient information for GP review. Additionally, a persistent hoarse voice was not widely recognized as a laryngeal cancer red flag by healthcare professionals or the public.
Responded
Janet Seddon
Concerns: A significant delay in investigating a missed abdominal pathology on a CT scan, which contributed to the patient's death, resulted in no proper harm assessment and a failure to disclose the error to the family.
Responded
John Turner
Concerns: Overwhelming demand on the Emergency Department led to deviations from triage protocols, delayed medical record keeping, and a reduced ability to identify serious conditions presenting atypically.
Responded
Megan Williams
Concerns: Deficiencies included unrecorded critical symptoms, poor clinician knowledge of the Acute Abdominal Pain Pathway, a flawed Serious Incident process, and a lack of clear self-discharge procedures.
Responded
Philip Ross
Concerns: The ambulance service's failure to timely clinically validate Category 3 and 4 calls, coupled with extended response times, places deteriorating patients at risk of early death.
Responded
Charles Daniels
Concerns: Inadequate nursing record-keeping and a failure to escalate a patient's significant deterioration to a doctor led to an unsafe discharge in very poor physical condition.
Responded
Kasey Beech
Concerns: The current STREAMing guidance's focus on chest pain in emergency assessments may delay recognition of other life-threatening conditions, risking sudden patient deterioration.
Responded
Dave Onawelo
Concerns: Inadequate monitoring of a high-risk patient with sickle cell anaemia, coupled with delayed interventions and emergency department issues like congestion and over-reliance on algorithms, contributed to a fatal outcome.
Overdue
Nimo Osman
Concerns: A significant delay in calling an emergency ambulance after a patient's collapse was exacerbated by a senior nurse's continued belief that nurses cannot call 999 without a doctor's approval, undermining training efforts.
Responded
Derryck Crocker
Concerns: A widespread lack of understanding and routine training among medical staff regarding air embolism signs, symptoms, and risks leads to delayed recognition and treatment, increasing fatality rates.
Responded
Marjorie Michael
Concerns: Persistent lengthy ambulance response delays for critical emergencies are caused by acute hospitals failing to promptly release ambulances, despite ongoing efforts, directly contributing to patient deaths.
Responded
Sandra Phillpott
Concerns: Despite prior concerns and reported improvements, there remains a persistent risk of sepsis going unrecognised and treatment being delayed at Blackpool Victoria Hospital.
Responded
Brian Colby
Concerns: A lack of clear protocols for escalating deteriorating patients and significant communication failures among clinicians led to delayed critical assessments. Misunderstandings regarding scan ordering and poor record-keeping also contributed.
Responded
Shelemiah Peterkin
Concerns: Staffing shortages caused delays in mental health referrals and patient care. Additionally, early warning sign assessments were not completed to standard, and action plans to improve this were missed.
Responded
Chloe Hunt
Concerns: The patient's complex trauma was not considered in her treatment plan, and there was inadequate assessment of complex foreign body removal. A lack of urgency and failure to recognise her deteriorating clinical condition contributed to critical delays.
Responded
Eric Thompson
Concerns: Critical abnormal blood results were not promptly documented or actioned in the emergency department due to a lack of electronic alert systems and over-reliance on unreliable verbal communication.
Responded
Robert Fray
Concerns: NHS Pathways' 999 system failed to escalate repeated calls and its duplicate checker, relying solely on location, led to delayed and misdirected ambulance dispatch.
Responded
Bernard Compton
Concerns: The emergency department lacked effective patient oversight and systems to action urgent blood results or ECG findings, alongside failures in ambulance service assessment and timely response for a critical cardiac condition.
Responded
George Broadhurst
Concerns: A national radiologist shortage leads to delayed X-ray reporting, risking missed fractures and diverting ED consultant resources. Additionally, community and primary care teams lack training to identify critical deterioration in fracture patients.
Responded
David Scott
Concerns: Hospital practice of not reporting vascular calcification on X-rays, even when it could indicate serious Peripheral Vascular Disease in conjunction with other symptoms, is inconsistent with expected standards and poses a risk.
Responded
James Pearson
Concerns: Lack of documented observations, insufficient doctor staffing for multiple critical patients, and delayed access to blood products hindered timely intervention, contributing to a patient's rapid deterioration and cardiac arrest.
Overdue
Carol Divall
Concerns: Basic nursing failures including inadequate oral care, mobilisation, and pressure sore management led to severe deterioration. A misleading discharge summary and insufficient root cause analysis further compounded the issues.
Responded
Michael Clarke
Concerns: Persistent significant delays for Category 3 ambulance calls and a lack of specific sepsis trigger questions on the ambulance pathway compromised timely emergency response, particularly for suspected sepsis.
Overdue
Ellen Mercer
Concerns: Hospital policy for VTE risk assessment is dangerously unclear, not requiring assessment in emergency departments and starting the 24-hour period only upon ward admission, despite long patient waits.
Responded
Thomas Wakefield
Concerns: Guidance for abdominal aortic aneurysm and acute pancreatitis lacks caution about their diagnostic overlap, risking fatal misidentification, even when imaging is advised for diagnostic uncertainty.
Responded
Tracey Farndon
Concerns: An overwhelmed emergency department with insufficient staff, coupled with staff's failure to recognize sepsis symptoms and critical low blood pressure, compromised patient safety.
Responded
Tommy Gillman
Concerns: Insufficient paediatric nursing staff, inadequate documentation and action planning during handovers, and a non-robust system for recognizing acutely ill babies in ED compromise patient safety.
Responded
Meha Carneiro
Concerns: Insufficient paediatric nurses, poor recognition of patient severity, inadequate PEWS escalation to senior doctors, and ineffective medical handover documentation compromised care in the Emergency Department.
Responded
Romeo Esposito
Concerns: Clinical staff repeatedly misattributed post-resuscitation respiratory effort to "a release of air" instead of re-assessing, and lacked training against this dangerous explanation.
Responded
Ernest Smith
Concerns: Repeated significant delays in medical reviews, commencement of antibiotics, and failure to follow the sepsis protocol led to compromised care.
Responded
Zachary Taylor-Smith
Concerns: Staff lacked critical understanding of neonatal deterioration and infection risks, exacerbated by poor communication between maternity and neonatal teams, and inadequate systems for patient reviews and capacity assessment for inductions.
Responded
Jean Thomas
Concerns: Significant ambulance and hospital offload delays, far exceeding targets, led to the formation and exacerbation of a pressure sore due to prolonged patient immobility.
Responded
Jennifer Trigger
Concerns: A miscommunication due to an inadequate bleep system caused critical delays in administering medication, leading to patient deterioration. The system's inability to electronically convey information risked proper task prioritization.
Responded
Ethel Reed
Concerns: Newly opened hospital wards suffered from peripatetic staffing and lack of leadership, hindering patient care and concern escalation. Additionally, electronic patient records failed to track author changes on discharge letters, risking miscommunication.
Overdue
Emily Harkleroad
Concerns: A new Emergency Department computer system lacks a clear RAG rating for patient acuity, making it difficult for clinicians to quickly identify critically ill patients, especially during peak demand.
Responded
Marjorie McEvoy
Concerns: Inadequate clinical notation by advanced nurse practitioners failed to sufficiently describe patient presentation, hindering appropriate escalation of care.
Responded
Lucas Pollard
Concerns: A Critical Care Team was not immediately dispatched, and an End Of Shift Policy was inappropriately applied, preventing a rapid response vehicle deployment, despite clear evidence of patient deterioration.
Responded
Terence Briney
Concerns: Clinicians risk missing treatable neurological conditions in elderly patients by attributing symptoms solely to old age instead of conducting thorough investigations.
Responded
Samuel Parkin
Concerns: Hospital learning points from a child's death were not formally disseminated, and ultrasound reports gave false reassurance about malrotation due to poor understanding of USS limitations, delaying crucial diagnostic tests.
Responded
Rhys Hill
Concerns: Ineffective communication, incomplete documentation, and unclear policies for medication management, VTE prophylaxis, and discharge safety led to gaps in patient care and potential risks.
Responded
Iona Buckingham
Concerns: The hospital's inability to provide immediate paediatric x-rays and chest ultrasounds outside of limited hours poses a significant risk to children with deteriorating pneumonia or suspected pleural effusions.
Responded
Tammy Watkins
Concerns: Persistent failures in physical healthcare within mental health settings, including staff not recognizing deteriorating patients, non-adherence to NEWS2 policy, and confusion in emergency call procedures, led to preventable deaths.
Responded
Karmchand Gulzar
Concerns: Failures in following surgical referral pathways, performing necessary CT scans, and recognizing patient deterioration due to communication issues and disregarded family concerns, despite previous warnings.
Responded
Lindy Aston
Concerns: A critically ill patient requiring urgent splenectomy was not operated on at Kettering General Hospital, despite the capability, resulting in a 24-hour delay and transfer that likely contributed to her death.
Responded
Sarah Chappell
Concerns: Multiple failures including delayed transfer, confusion over lead clinicians, inadequate pain relief, and critical mismanagement of a nasogastric tube led to a fatal aspiration. The hospital failed to conduct a proper investigation.
Responded
Michael Vincent
Concerns: An elderly patient suffered a fatal cardiac arrest after a ten-hour ambulance delay following a fall. The severe missed response target highlights a risk of future deaths from prolonged lying and related injuries.
Overdue
Shiya Collins
Concerns: A computer system's "locking facility" prevented clinicians from accessing and upgrading a patient's ambulance response, despite multiple calls highlighting their deteriorating condition.
Responded
Geoffrey Whatling
Concerns: A care home failed to monitor a patient's food/fluid intake and observations, did not call emergency services for a high NEWS2 score, and had incomplete records, with no apparent actions taken after the death.
Overdue
Myra Maxfield
Concerns: Delays in patients seeing the Tissue Viability Team, specifically due to its unavailability over weekends, put patients at risk of death from pressure ulcers.
Responded
Kirsty Hendry
Concerns: Low awareness among primary care professionals regarding key symptoms of a burst aneurysm results in delayed identification and referral, impacting vital early treatment.
Responded
Thomas Doyle
Concerns: The sepsis diagnostic pathway was repeatedly not commenced despite the patient meeting severe sepsis criteria, contravening Trust policy and delaying critical treatment.
Responded
Wayne Milne
Concerns: Inconsistent 999 call procedures and inadequate nurse training for chest pain emergencies, coupled with low awareness of critical conditions like Dissecting Aortic Aneurysm, led to fatal delays.
Overdue