Laxmi Thakker

Lack of bedside observation chart hinders rather than assists clinical assessment of patients. This represents a real step- back in the provision of patient care.

Lack of training at CUH in the nursing staff in relation to the existence of and when to call the “site” or “critical outreach team’.

Problems with telephonic communications on the CUH site.

Problems with systems in place for the administration of blood at CUH.

Lack of escalation of clinical concerns from junior to senior staff at CUH, and in particular that a patient could collapse, be seen by a junior from another treating

team and the patient’s own senior team not be promptly informed, as well lack of escalation of clinical issues within the same team.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you [AND/OR your organisation] have the power to take such action.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report. I,

the coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.

COPIES and PUBLICATION

| have sent a copy of my report to the Chief Coroner and to the following Interested Persons :

Miles Scott

Chief Executive

St George’s Hospital Blackshaw Rd London SW17 0QT

| have also sent it to the following persons or organisations who may find it useful or of interest:

Simon Stevens Chief Executive NHS England PO Box 16738 Redditch

B97 9PT

| am also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

28" April 2016

Qe

/ Dr Fiona 4 Wilcox HM Senior Coroner Inner West London Westminster Coroner’s Court 65, Horseferry Road London SW1P 2ED