Coroners report Archives

NHS Trust death: Inquest into St Albans woman’s empty oxygen cylinder

Posted on 21 January 202527 March 2025 by Sarah O'Sullivan

An inquest into the death of a woman under the care of West Hertfordshire Teaching Hospitals NHS Trust began on Monday 20 January.

Incident overview

Cecilia Harper (71) died in Watford General Hospital on 9 February 2022, while being transported from her ward to the radiology department. She had been admitted to the hospital five days earlier.

Circumstances leading to her Death

The mother-of-two had reported breathlessness while in hospital, after initially being provided with oxygen via nasal cannula, her oxygen dependency increased and Cecilia was provided with an non-rebreather oxygen mask for the journey and was accompanied by a porter and student nurse. She was conscious when she left the ward, yet by the time she arrived in the ultrasound room she had lost consciousness. A number of medical staff undertook CPR but Cecilia had sadly died.

Investigation findings

Upon investigation, it was discovered that Cecilia’s oxygen cylinder was empty, it was not clear when this occurred. During the first day of the inquest, it was heard that research carried out by a doctor at the Trust indicated that 10% of patients transferred to the A&E CT department have insufficient oxygen for a return journey, while 9% of patients made the journey with oxygen cylinders switched off.

However, a post-mortem report, which identified metastatic breast carcinoma as the cause of death, made no mention of the impact of the empty oxygen cylinder or oxygen dependency.

The inquest proceedings

An inquest took place at the Coroner’s Office for the Area of Hertfordshire to determine the cause of Cecilia’s death. There have been two previous inquest review hearings to ensure all appropriate evidence has been sought, which has delayed proceedings.

The inquest, which was expected to take place over three days, concluded on Tuesday (21 January). The inquest sought to confirm the exact circumstances surrounding Cecilia’s death.

The coroner determined that Mrs Harper died from natural causes, but it is unclear whether there was any problem with oxygen supply, and it is unclear if there was a problem with oxygen supply, if it contributed to her death.

There was not a determinative finding because of the contradictory evidence and lack of documentary evidence relating to the timings of when things occurred.

Concerns raised by Tees Law

Tees Law, acting for Cecilia’s family, has highlighted possible breaches in regulations by West Hertfordshire Teaching Hospitals NHS Trust.

Hospital staff have reported different times for the length of Cecilia’s journey from her ward to the ultrasound room, however it is understood to have taken at least six minutes. Moreover, it is believed to be contrary to best practice for a porter and a trainee nurse to accompany a patient in the way Cecilia was transported. Instead, she should have been accompanied by appropriately trained professionals.

Statement from Tees Law

Sophie Stuart of Tees, acting for the family, said: “These tragic events pose many questions about the use of oxygen cylinders for patients within West Hertfordshire Teaching Hospitals NHS Trust.

Cecilia’s family is hoping that the inquest will help shine a light on what happened to Cecilia. By highlighting any failings in her care, the family hope that the Trust will address a wider problem in order to ensure this never happens to any other patient.

It is also worth noting that NHS England issued Patient Safety Alerts in relation to oxygen cylinders in 2018 and 2023. Our concern is that despite these alerts this issue still seems to be a problem and could be affecting other patients.”

Remembering Cecilia Harper

Living in St Albans at the time of her death in her early 70s, Cecilia had many jobs throughout her life. Notably, she worked in Hong Kong, managing American expatriates in South-East Asia for the global technology firm IBM. She returned to the UK in 1983, where she lived ever since with her husband John.

Baby loss awareness week: The heartbreak of Lisa and Ryan

Posted on 4 October 202427 March 2025 by Sarah O'Sullivan

Lisa Buttery (36) and fiancé Ryan Barnes (37) had always wanted to start a family, but despite years of trying, they had never been able to conceive. In November 2021, they eventually found out they were pregnant with baby Isla Grace and were overjoyed to finally become parents.

This would be their first child. They put their wedding planning on hold while they prepared for their new arrival.

“Our little miracle”

The pregnancy went smoothly, and baby Isla was growing well. Lisa was referred to the John Radcliffe Hospital in Oxford, where a plan was made for induction of labour at 42 weeks.

Following induction, Lisa’s labour progressed quickly, but baby Isla soon began to struggle. Concerns were first raised by midwives shortly after Lisa’s waters broke, as CTG’s (fetal monitoring equipment) suggested that Isla Grace was getting a limited supply of oxygen during labour. A plan was made to transfer Lisa to the delivery suite, but no beds were available at the time.

In the hours that followed, further concerns were raised by midwives, who felt that Isla’s heart rate was fluctuating dangerously. On three separate occasions, recommendations by the midwives to escalate Lisa to an emergency caesarean section were overruled. Eventually, Lisa was taken for a category two emergency caesarean section. A category two caesarean section is initiated where there is fetal or maternal compromise which is not considered life-threatening. Despite attempts at resuscitation, Isla tragically died at just 19 minutes old.

A coroner’s inquest took place in March 2023, which concluded that Isla died from hypoxic brain damage, signs of which were seen on electronic foetal monitoring (CTG recording).

The process

Lisa and Ryan approached Tees to help guide them through the inquest process and to bring a claim for compensation on behalf of Isla Grace.

Following initial investigations, Tees were able to secure a response from the hospital, who admitted that they failed to refer Lisa for an emergency caesarean section once concerns were raised around Isla’s wellbeing. They admit that, had Lisa been sent for an earlier caesarean section, then Isla would likely have survived.

A word from Lisa and Ryan

“Losing our beautiful daughter Isla Grace has forever changed us as people – it is a story we never thought imaginable, let alone something we will now have to live with for the rest of our lives. And that is exactly what it is – a life-long heart break knowing you will never feel true joy again without our first and only child in this world.

We contacted Tees to find answers and justice for Isla as both internal and external investigations didn’t reveal an underlying cause of death. We see that the only benefit that can come from this is change – change to processes, change to assumptions, change to maternity care that we hope will save the lives of thousands of babies – and our hope is that that will be Isla Grace’s legacy.”

Thank you to Lisa and Ryan for giving Tees permission to share their story on Baby Loss Awareness Week, in memory of Isla Grace.

If you are concerned about the care you or your baby received, you can talk to one of our specialists. We’ll listen to your experience and help you get to the truth of what happened.

Coroner: Baby’s death at NHS Trust due to neglect

Posted on 22 May 202427 March 2025 by Sarah O'Sullivan

A baby who died from a brain injury following a delayed labour and delivery was failed by staff at Sherwood Forest Hospitals NHS Trust, a Coroner has concluded.

Arlo River Phoenix Lambert died on 9 March 2023 at Kingsmill Hospital, Nottinghamshire, at five days old. The Coroner found that Arlo’s death was “contributed to by mismanagement of labour and multiple missed opportunities to have expedited his delivery.”

She concluded that neglect contributed to Arlo’s death, which came from “a failure to follow Trust guidance.”

Miss Lambert, Arlo’s mother, was induced at 40+2 weeks, and following spontaneous rupture of membranes (SROM), she was left for 17 hours without any attempts made to progress her labour. The Coroner found that this allowed the risk of infection to materialise. During that time, staff failed to properly review Miss Lambert’s care plan and discuss modes of delivery with her when concerns were raised about the position of the baby and her labour was failing to progress.

Coroners findings on contributing factors

The Coroner concluded that neglect contributed to Arlo’s death, citing a “failure to follow Trust guidance.”

Miss Lambert, Arlo’s mother, was induced at 40+2 weeks. After a spontaneous rupture of membranes (SROM), she was left for 17 hours without attempts to progress her labour. The Coroner found that this delay allowed the risk of infection to materialise. Staff also failed to properly review her care plan or discuss delivery options when concerns arose about the baby’s position and the lack of labour progression.

Missed opportunities and preventable death

The Coroner identified “multiple missed opportunities to have expedited Arlo’s delivery, which would probably have prevented his death.” A Prevention of Future Deaths Report has been issued.

Since Arlo’s death, Miss Lambert has experienced post-traumatic stress disorder (PTSD).

Complaint against specialist registrar

Additionally, the Coroner made a complaint to the General Medical Council regarding the actions of Specialist Registrar Dr Adeyemi. In oral evidence, he stated that he would “cross [my] fingers behind my back and hope and pray the mother would go into labour” rather than implementing an appropriate care plan.

Evidence of brain injury

A post-mortem autopsy confirmed that Arlo’s brain had suffered a hypoxic-ischaemic injury, caused by a lack of adequate oxygenated blood supply. This was attributed to the delayed delivery following fetal distress.

Failings in antenatal and labour care

The Coroner found significant issues in Miss Lambert’s care between her induction of labour on 2 March 2023 and Arlo’s birth on 4 March 2023.

Antenatal failings

At 38+6 weeks gestation, Miss Lambert underwent a growth scan and was offered induction at 40+2 weeks due to concerns about fetal growth. However, the Coroner concluded that this decision was outside national guidelines, and Miss Lambert was not informed that the induction was unnecessary. The Coroner stated that she would likely have gone into spontaneous labour without complications.

Labour management failures

Upon Miss Lambert’s admission, numerous delays in commencing the induction occurred, exacerbated by poor communication and staff shortages.

At 11:33 on 3 March, a high fetal head position was noted, presenting a missed opportunity to consider a delivery plan. Additionally, the decision to discontinue CTG monitoring, against national guidance, prevented the detection of fetal distress.

By 17:00, Dr Adeyemi formulated a delivery plan without consulting Miss Lambert, reviewing her records, or considering her preferences.

The Coroner concluded that had the Trust’s induction of labour policy been followed, and delivery occurred within two hours of SROM, Arlo’s death could have been avoided.

Delayed caesarean section and birth complications

At 21:43, a further opportunity was missed when blood-stained liquor was reported. A lack of communication between the midwife and obstetric team meant that the mode of delivery was not reconsidered.

Doctors eventually opted for a category 1 caesarean section at 03:58 on 4 March, following concerns of placental abruption. At 04:26, Arlo was delivered via a difficult caesarean, with evidence of a placental abruption. Despite specialist care at the Queen’s Medical Centre, he died five days later.

Specific failings identified by the Coroner

The Coroner outlined the following key failings:

Failure to follow the Trust’s induction policy.
Inadequate monitoring of fetal distress.
Poor communication and staff shortages.
Lack of consideration for Miss Lambert’s informed consent.

Had Arlo been delivered sooner, the Coroner concluded that he “would more likely than not have survived.”

Calls for maternity care reform

Following a series of high-profile scandals, NHS Trusts face mounting pressure to improve maternity care. A recent Birth Trauma Inquiry condemned poor maternity and postnatal care as “tolerated as normal,” calling for systemic reform.

Family’s response and legal representation

Chantae Clark of Tees Law, representing the family, stated:

“These tragic events were preventable if Sherwood Forest Hospitals NHS Trust had followed the guidance and acted on the warning signs in the hours before Miss Lambert’s labour. It is hard to believe that in such an advanced healthcare system, a mother should suffer the treatment that she did and that a baby should die because of neglect.”

She emphasised the emotional toll on Arlo’s family and expressed hope that the Coroner’s findings and Prevention of Future Deaths Report will lead to meaningful changes in NHS maternity care.

NHS Trusts respond after accepting liability for avoidable death of mental health patient

Posted on 14 March 202427 March 2025 by Sarah O'Sullivan

Two NHS Trusts that accepted liability for the preventable death of Jack Farrington have responded to the Regulation 28 Prevention of Future Deaths Report, outlining changes that they have since made to improve patient safety.

Solent NHS Trust and Portsmouth Hospitals NHS Trust have accepted full liability for the preventable death of Jack Farrington, a 26-year-old man who took his own life while detained under section 2 of the Mental Health Act in January 2020.

Trust Failings and Areas for improvement

The Trusts’ failings were found to have contributed to Jack’s ability to abscond from the hospital. Key areas requiring improvement include:

Assessment and recording of patient information
Information sharing
Accountability
Implementation of measures to ensure patient safety

Actions taken by the NHS Trusts

Portsmouth Hospitals NHS Trust’s response

Portsmouth Hospitals NHS Trust stated that it is developing a new system to provide the Emergency Department team with more comprehensive information about patients’ needs and risks before their arrival.

Solent NHS Trust’s response

Solent NHS Trust announced that it is transitioning from paper-based forms to an electronic system integrated with the existing online platform, improving the accuracy and accessibility of patient information.

National NHS response

Professor Sir Stephen Powis, National Medical Director of NHS England, highlighted that Summary Care Records now include details of long-term conditions, significant medical history, and specific communication needs by default, unless a patient has opted out.

Jack Farrington’s story

Jack Farrington, who lived with bipolar disorder and schizophrenia, tragically died after absconding from Queen Alexandra Hospital in Portsmouth. He fell from a bridge over the A3 London Road in January 2020.

Legal action and family’s response

Jack’s parents, Joseph and Catherine Farrington, pursued a civil action against both Trusts with the support of Tees Law. The legal claim concluded in January 2024.

Chantae Clark, from Tees Law, commented on the significance of the case:

“This case underscores the pressing need for improvements in mental health care and highlights the importance of robust oversight and accountability across the NHS and mental health services.”

Findings from the inquest

An Inquest concluded that Jack was not capable of forming an intention to end his life. When he was lucid, he showed a desire to recover and sought medical assistance.

Timeline of events leading to Jack’s death

30 December 2019: Jack called 999 during a psychotic episode and was voluntarily admitted to Queen Alexandra Hospital (QAH).
Initial Risk Assessment: Jack received a ‘Mental Disturbance Primary Survey’ with a risk score of 8, the highest level, requiring Level 5 (black) supervision.
First Absconding Incident: While waiting for further assessments, Jack absconded through an emergency exit.
Second Absconding Incident: After being returned to the hospital by the Police, Jack absconded again the following day.
Detainment and Transfer: Jack was sectioned under Section 2 of the Mental Health Act and transferred to the Hawthorn Ward under Solent NHS Trust.
Insufficient Risk Consideration: Despite his history of absconding, his risk was not properly addressed by the Hawthorn Ward.
Seizure and Return to QAH: On 2 January 2020, Jack suffered a seizure and was returned to QAH, where he was placed in the Emergency Department’s “Pitstop” area.
Final Absconding Incident: Jack absconded once again and tragically took his own life.

Coroner’s prevention of future deaths report

The Coroner issued a Prevention of Future Deaths Report, warning of the risk of future deaths without appropriate action. Key concerns included:

Inadequate handovers
Poor record keeping

The Report was directed to Solent NHS Trust, Portsmouth Hospitals NHS Trust, and NHS England.

Conclusion

Chantae Clark of Tees Law emphasised the importance of the legal process in driving change:

“Whilst the Inquest process and pursuing legal action cannot undo the pain caused by Jack’s tragic death, I hope that the conclusion of this case, coupled with the Coroner’s Prevention of Future Deaths Report, serves as a catalyst for change.”

Jack’s family, supported by Tees Law, remain committed to ensuring that lessons are learned to prevent similar tragedies in the future.

Aortic dissection medical negligence claims

Posted on 18 November 202128 March 2025 by Sarah O'Sullivan

Aortic dissection is a serious condition that can impact at any age.

It is essential that aortic dissection is detected early, as when treated quickly there is a very good chance of survival. Sadly, when delays in diagnosis happen it can lead to catastrophic outcomes.

Jacob Hassan was a father of two, who died after having an aortic dissection aged 62.

Jacob, a keen cyclist who regularly cycled 100 miles a week, had worked as a GP for over 30 years before taking early retirement. He lived in Cambridge with his wife, Sharon, and loved visiting his grandchildren in Indonesia and Australia.

His death followed a trip to A&E after Jacob had experienced intense chest pain. He was discharged with a diagnosis of “non-specific chest pain” without being offered the scan that would have saved his life.

What is aortic dissection?

Aortic dissection occurs when there is a partial tear in the aortic wall. The aorta is the main artery that carries blood away from the heart. If a tear develops, it can allow blood to leak into the aortic lining, which can create a false channel between the inner and outer layers.

Many of the symptoms of aortic dissection are similar to those of other heart problems like heart attacks. Usually, the first sign of an aortic dissection is abrupt and severe chest, back or abdominal pain. The sensation is often described as ripping or tearing.

How is aortic dissection diagnosed?

Aortic dissection is not common and it can also be difficult to diagnose. That’s why it’s so important to have a specialist CT scan. In Jacob’s case, this could have been performed on-site to provide a quick and definitive diagnosis. When diagnosed and treated quickly, the survival rate for aortic dissections is better than 80%.

According to the Aortic Dissection Charitable Trust, however:

33% of sufferers are misdiagnosed
2,000 people die each year from aortic dissection in the UK

Like Jacob, most patients with aortic dissection suffer sudden severe chest pain, which can settle completely after a few hours. Routine tests carried out in the Emergency Department can come back normal. Only a specialist CT aortogram can conclusively say one way or the other whether a patient has an aortic dissection.

Case study of failure to diagnose aortic dissection

Jacob’s story is tragic and his death avoidable.

On a cycle ride from Cambridge, Jacob had to pull over because he was breathless. For an experienced cyclist like Jacob, this was an unusual occurrence. That same evening, he complained of chest pains, telling his wife Sharon to call an ambulance.

By the time he arrived at Addenbrooke’s Hospital’s A&E Department his chest pain was intense. The triage nurse noted the pain was stabbing in nature and radiated to the back – both classic symptoms which should have alerted staff to the need for a CT scan.

Jacob was given painkillers and a chest X-ray but was discharged without being offered a CT scan. A common scenario with aortic dissection is that it can be dismissed because patient doesn’t seem ill enough.

The pain subsided but Jacob continued to lack energy over the next few days. Then, one evening, his wife Sharon returned home to find Jacob collapsed and unresponsive. He died later that night.

Classic signs of aortic dissection missed

The decision to discharge Jacob without offering him a CT scan, despite his unexplained chest pains, was a tragic mistake. According to the coroner, a CT scan would have led to a diagnosis of aortic dissection and saved Jacob’s life.

The Coroner’s Record of Inquest noted that “The presentation of chest pain being severe, sharp, and radiating to his back was indicative of acute aortic syndrome… and should have triggered CT aortography at the hospital which would have confirmed the presence of such a dissection.

“This would have necessitated emergency cardio thoracic surgical intervention and on balance, Jacob would have survived such a procedure.”

Cambridge University Hospital NHS Foundation Trust failed to offer a CT scan and there was also a communication issue with the A&E department not being able to access to the electronic notes of the ambulance crew.

Seeking justice and raising awareness

With the help of Partner Tim Deeming in our medical negligence team, Sharon Hassan is proceeding with her case.

Once the Coroner commenced the inquest investigations, independent experts confirmed Jacob’s death could have been avoided if the cause of severe chest pain had been thoroughly investigated.

Through the case we aim to raise awareness of the effectiveness of CT scans in identifying aortic dissection.

As Sharon said: “Unless the Health Authority has a system to offer a scan to all those presenting with chest pain that cannot be explained by a heart attack, pneumothorax or pulmonary embolism, tragedies will continue” she said. “I just want to ensure no family has to go through what mine has.”

Tim Deeming, Partner acting for the family added: “It’s vital we raise awareness through shared knowledge. As a lawyer supporting families who have had such challenging circumstances, it is through shared experiences we can improve services and learn.”

“It’s about systems and it’s about support… we hope wider training can be provided about Jacob’s circumstances and we want to create a legacy so that CT investigations for aortic dissection are considered basic and fundamental to rule out.”

Medical negligence advice and help

Our medical negligence solicitors are devoted to achieving the support our clients and families need. If you or your family has been affected by potential concerns regarding your medical care, we can support you on your journey.

Bright graduate died after GP practice dosage error

Posted on 28 January 202130 March 2025 by Sarah O'Sullivan

West Sussex Assistant Coroner Ms Henderson has concluded an Inquest into the tragic death of a 30-year-old man who had been receiving medication for severe back pain at a village medical practice. It points to shortcomings in the treatment given by the practice in Loxwood.

This week’s hearing and an adjourned hearing at Crawley in January learned that Leeds University graduate Hamish Hardie died in August 2019 at the family home in Wisborough Green from an accidental overdose of prescribed painkillers, for which the dosage label was unclear.

Hamish required pain relief for severe back pain caused by two prolapsed lumbar vertebral discs, for which he was waiting for private surgery, and was dealt with at Loxwood by a qualified doctor who was in his final year of GP training under the supervision of a senior GP.

Dosage not specified

The doctor prescribed two opiate painkillers, Dihydrocodeine and Oramorph, as well as the relaxant Diazepam. The prescription for the Oramorph on the label tragically said it should be taken as directed, which was unclear. Sadly, this was also not identified by the dispensing practitioner within the pharmacy at the practice.

Hamish’s mother Mary-Anne took responsibility for administering the medication, but the uncertainty about the Oramorph label and reliance on Hamish for dosage details meant that more frequent and higher doses were given.

Sadly, Hamish died two days later and a post-mortem confirmed that the primary cause was a prescription drugs overdose, which the Coroner concluded was accidental. The trainee and supervising GPs did not recall seeing an alert on the medical records and the computer system meant that with an Oramorph prescription its labelling default standard was ‘use as directed’.

“We still feel that Hamish was badly let down that day and that his life was unnecessarily cut short by medical failings,” Mary-Anne Hardie reflects. “It was May 2019 when Hamish developed back pain from a suspected slipped disc. That was confirmed on an A&E visit in June, when he was given Diazepam and put on the list for a possible operation. We are disappointed that the GPs did not see the alert on the computer and that if the labelling and prescription advice had been clear, or the pharmacy had spotted the inconsistency, then we feel that Hamish would still be here as he was looking forward to job interviews and a new chapter in his life.”

A ‘perfect storm’

Specialist solicitor Tim Deeming of Tees Law adds: “The Coroner described this as a perfect storm and it is tragic that the GPs did not know that the labelling system defaulted, and that the pharmacy did not then spot this.

“While we are glad to know that the Loxwood Medical Practice has made significant changes to procedures following Hamish’s death we all hope that the NHS and GPs will take steps when providing such prescriptions to provide clear guidance on use, as well as checking computer systems to ensure that other families do not have such devastating outcomes.”

Timely treatment might have saved devoted wife and grandmother

Posted on 26 October 202030 March 2025 by Sarah O'Sullivan

A retired wife and grandmother tragically died in hospital after multiple opportunities were missed to administer appropriate treatment that could have saved her life, an inquest at the Suffolk Coroner’s Court in Ipswich concluded after a two-day hearing.

HM Senior Coroner for Suffolk, Nigel Parsley, heard that 61-year-old grandmother Karen ‘Jane’ Winn from Northwold near Thetford, Norfolk, died at the West Suffolk Hospital in Bury St Edmunds on Monday 15 April 2019, four days after being diagnosed with a suspected urinary tract infection by her GP.

Jane was prescribed antibiotics by her GP on 11 April, but she returned next day as she was by then very unwell. She was referred straight to hospital and admitted the same day. That evening a senior medical consultant diagnosed Jane’s condition as haemolytic anaemia, a serious blood disorder.

Haemolytic anaemia depletes oxygen-carrying red blood cells and medical staff identified that Jane was at risk of developing a deep vein thrombosis, which can result in a life-threatening pulmonary embolism if a blood clot reaches the lungs. So, correct intervention at that point was vital for Jane.

Once the haemolytic anaemia diagnosis had been made, the immediate response should have involved blood transfusions plus ‘prednisolone’ steroids and folic acid. Anticoagulant medication was intended to be given, subject to the result of a repeat blood test to assess internal bleeding risk.

Anticoagulant delayed

Jane initially received only blood transfusions and antibiotics. Not until 14 April were steroids and folic acid administered, whilst no prophylactic anticoagulant was given until 15 April, by which time it was too little, too late to disperse any blood clots that had formed during the previous 72 hours.

An automated venous thromboembolism (VTE) risk assessment warning system is embedded into the electronic patient monitoring for all patients. Disturbingly, this VTE system was manually overridden 58 times between 12 and 15 April, despite Jane’s increased risk of blood clots.

Sadly, soon after transfer to the intensive care unit and an hour after her first and only dose of anticoagulant, Jane suffered a fatal cardiac arrest. This was the outcome that Jane’s distraught husband Brian and the wider family had feared and one they believe could have been avoided.

“We are bitterly upset that such an essential part of the treatment available for Jane’s illness wasn’t used promptly,” says a close family member. “The right diagnosis was made, but life-saving medication was given too late, despite repeated reminders. Our hope now is that lessons learned will prevent the same thing happening to anyone else.”

Significant blood clots

The primary cause of death, a bilateral pulmonary embolism, with deep venous thrombosis and haemolytic anaemia as contributory causes, was confirmed at post-mortem. Widespread pulmonary emboli in the lungs and significant blood clots in veins of the upper leg were both evident.

In summary, the Coroner concluded that Jane’s death resulted from the progression of a naturally occurring illness, contributed to by the non-administration of medication to prevent blood clots despite being earlier identified as essential for her treatment; the latter amounted to neglect.

Tees Law, acting for the bereaved family, comments: “A venous thromboembolism risk assessment is mandatory for all patients admitted to hospital and should be completed within hours of admission. It was wholly unacceptable for the assessment alert to have been overridden 58 times over those four days. The Coroner’s finding of neglect acknowledges the total failure to give Jane basic medical treatment that would ultimately have increased her chances of survival.”

Read the full story here.

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