Every single day of my life I remember how Coroner Radcliffe smirked as she dramatically grabbed her pencil and scribbled off action point 10 of the SUI (individual learnings). A point that was completed a year earlier and a point to this day the Trust stands by as necessary.
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I independently asserted that
@JusticeForHBN's PEWS of 5 was really "only" 4 when his lactate was 7.5 and CO2 10 (respiratory failure) Apparently the parents are a bit upset about that because they argue PEWS of 5 did accurately foreshadow the baby's death. Meh details..
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And no doctor except for me (glorious coroner) "accepted" that sleep and unconsciousness are distinct factors for scoring. Infact the new PEWS guidelines continues to count for sleep and unconsciousness. Oh well. Sucks to be the parents I guess

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What does "human decency" mean? I'm so proud of repeated saying this at that child's inquest: "PEWS score was 4 but that included 1 for level of consciousness which we now accept means 3" It's hilarious because I know the PEWS was accurate cause the child died.
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.. The court had moved to a temp location so it was a last minute rush to find out where we needed to go.
Coroner's office promised we would get a reply to our letter within a week. 10 months and counting...