Brian Havard

The doctor had not read the ambulance electronic records and was not aware of a system in place to obtain these notes prior to his seeing the patient: These notes contained information about Mr Havard having hematemesis and two doses of morphine given to Mr Havard by the crew: He did examine Mr Havard and had differential diagnoses and went to speak to the locum consultant who was just coming on shift for advice: The consultant did not ask to see the notes from the crew or the hospital notes and was just shown the ECG: He evinced no professional curiosity about a him, patient needing three doses of morphine and being considered for discharge: The locum consultant did not seem to be aware of any system in place to access the ambulance electronic records: He did not give any convincing explanation for not seeing this patient or his apparent ignorance regarding obtaining ambulance notes: He did not give a convincing explanation for not reviewing the patient There did not appear to be a system in place for junior doctors who have approached a senior to have their case reviewed with the responsibility for this being on the senior doctor_ Record keeping generally appeared to be poor and thus the doctors who attended at inquest had little documentation with which to refresh their memories and the ambulance notes do not appear to be routinely included in these notes and or read: