Frederick Sutton

(1) The staffing levels in the hospital during his seemed to be less than optimal: (2) Whilst there is a procedure for escalation of the shortage of staff, this was either not fully understood or not properly put into effect: (3) There was clear evidence that a nurse had failed to read (or read properly) the nursing notes_ (4) The computerised note keeping system used in the Emergency Department is not able to "talk to" the system which covers the rest of the hospital: (5) The patient required the administration of cyclazine and there was an obvious problem with the (lack 0f) training of the staff in this regard.

(6) The patient suffered a cardiac arrest and there was a lack of understanding amongst nursing and medical staff as to how this ought to have been responded to. There seemed to a lack of training amongst the staff as to the_ July stay administration of certain prescribed drugs, both as to the appropriate amount thereof and the method of delivery_ (8) There was a general lack of care as to the accuracy of the information held by the hospital as to next-of-kin details, where the wife of the deceased was shown as no.k when in fact she had died in 2008