I wonder what sort of flaws holes and harms might be anticipated if previously high performing clinical staff were inundated with too much work, too many ill children, IT offline and no senior to turn to for help? @djnicholl @DrJennyVaughan @gmcuk
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Replying to @doctorcaldwell @BoyGeekDrone and
If the M25 becomes too busy on a dark night with mist ice and snow this renders competent accident free drivers incompetent and the police know there will be accidents. What conditions would render a Doctor and Nurse to become incapable of safely driving ill children to health?
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Replying to @doctorcaldwell @BoyGeekDrone and
An ability to process numbers given to her over the phone instead of relying on them done in 'red for danger' on a graph for her would help. Aviation & naval jobs require to have great recall knowledge, knowing that part of their system, may fail and they will be without support.
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Replying to @Janine00050361 @doctorcaldwell and
You make it sound so simple. Juggle all the usual work complexity, throw in systems issues, staffing and other factors and still take on board all the data and interpret it well.
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Replying to @BoyGeekDrone @doctorcaldwell and
Jack's skin was also showing signs, in fact he was displaying all the signs of septic shock when he arrived, the reading should have been confirmation. I'm not saying you job isn't hard. No one is.
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Replying to @Janine00050361 @doctorcaldwell and
I think it's safe to say that our understanding of sepsis,including its recognition and management, have moved on alot since the tragic case of Jack. Jack could have had any number of initial differentials including gastroenteritis which is what his presenting features where.
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Replying to @BoyGeekDrone @Janine00050361 and
What I can’t get over is the degree of acidosis, hypoxia, peripheral shutdown and then raised Inflamatory markers and deranged U&E’s. With that blood gas and presenting features why wasn’t he safety netted to PICU or Consultant review?
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Replying to @doctorcaldwell @lynn_laidlaw and
I guess that's where consultant supervision plays a role. Also, she had treated him and I believe there was improvement biochemically and clinically which though fleeting, we know now, would have been falsely reassuring.
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Replying to @BoyGeekDrone @lynn_laidlaw and
The On Call Consultant was at a meeting outwith the Hospital and a stand in had not been arranged, then the stand in chose not to go to review Jack. The stand in must have had many sleepless nights even living in a country outside the jurisdiction of
@gmcuk ?1 reply 0 retweets 2 likes
The 'stand in'? Is this referring to Mr O'Riordan or somebody else?
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