“For patients remaining for a considerable period of time in the Accident and Emergency…”

The coroner’s concerns

1. For patients remaining for a considerable period of time in the Accident and Emergency Department there is no clear indication or understanding as to who is responsible for the overall patient's clinical care. 2. EWS scores indicated that a clinical review was mandated for which there is no evidence in the medical records that any such review took place by A & E medical staff or that the matter was referred to any of the other clinical teams. 3. When the NG tube was unable to be sited and no obvious clinical review in response to the EWS scores had occurred, there is no evidence of escalation by the nursing staff either through the nursing hierarchy or the medical hierarchy. 4. The Trust's Serious Incident Review to identify the root causes of the incident raises the following concerns concerning the adequacy of the Trust's investigation and measures taken: a. NG tube not sited - the Trust's response does not address why there was a failure of escalation or referral back to the requesting teams and the updated action plan that "training on insertion should shorten time taken to decompress" is inadequate; b. that the EWS score mandated review by the acute care team (whoever that may Coroner's Court, 2 Faraday Court, Faraday Drive, Fulwood, Preston, Lancashire, PR2 9NB Tel 01772 536536 | Fax 01772 530752 be for these purposes-see first point), there is no evidence in the medical records apart from a blood gas that any such review took place or that any treatment occurred; c. the investigating consultant had informal conversations during the investigation with a middle grade doctor who had performed the arterial blood gas but was unable to state who this was, why no medical records were created and why no action was taken d. the report states that there was a "correct escalation of the EWS at every stage" for which no evidence has been provided and appears to be factually incorrect e. medical records created by the surgical registrar were in accurate as they were completed by a junior doctor and not checked f. that no audit has taken place to ascertain whether the Trust's measures have had the appropriate effect.

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, 2021-0040

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