“Evidence was given to me that observation of patients are conducted throughout the…”

The coroner’s concerns

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— (1)Evidence was given to me that observation of patients are conducted throughout the Hospital using an Early Warning Observation Chart. The observations are often recorded by unqualified Health Care Assistants but the recordings should be checked and interpreted by a qualified nurse. A trigger score is given for each set of observations; one trigger should result in a review by a senior nurse and an increase in the frequency of observations, two triggers requires a review by a doctor and three triggers a review by a specialist registrar. The chart is a tool to ensure that there is an escalation of care to an appropriate level. (2) In the case of Mr. White the EWS chart was not completed correctly, triggers were ignored and none of the observations were checked by a qualified member of staff. The evidence of Dr. WE an independent expert was “This resulted in lost opportunities to reassess Mr. White and put in place the necessary resuscitative measures. (3) | was also told that there is no regular audit system in place to ensure that the charts are correctly completed, interpreted and acted upon.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2014-0395

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0