“The Trust’s care plan no 94 RIG was not followed”

The coroner’s concerns

– (1) The Trust’s care plan no 94 RIG was not followed. The SI report dated the 20 August 2015 (page 19) recommends that relevant staff members are aware of and understand the policies, guidance and supporting documentation which relate to the care of patients who have undergone enterostomies. I was informed this recommendation had not yet been put into effect. (2) There were considerable difficulties in escalating Mr Crofts’ care on 20 and 21 September 2014. The SI report recommends that the process by which care is escalated within and between disciplines needs to be reviewed and clarified to ensure that patients receive timely attention. Again, I am not satisfied on the evidence I have heard that this recommendation has been implemented. (3)There were considerable difficulties obtaining a CT scan on Sunday, 21 September 2014. This was partly because it was not actioned at 16.00, when requested. After 17.00 on the weekend the request had to be made by a consultant to an outside provider Medica who read the scans when no-one is available at the hospital. It appears that junior doctors can now request CT scans and that a new arrangement is being put in place to obtain urgent CT scans in cases of suspected peritonitis. The SI report recommends that guidance relating to CT scanning on the trust intranet should be reviewed to clarify the process for arranging investigations and be made available as part of the induction process for junior doctors and on the ward areas, for other staff to access. I was informed this has not yet been actioned. (4)During the course of evidence it became clear that the delay in attempts to escalate Mr Crofts’ care over the weekend was due in large part to staffing levels. Whilst I heard that staffing levels at weekends have increased since 2014, it was not clear that the number of doctors at all levels of seniority available at weekends is sufficient to provide safe care to in patients at the hospital particularly at times when emergencies arise in A and E.

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, 2016-0066

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