Peter White

(1)Evidence was given to me that observation of patients are conducted throughout the Hospital using an Early Warning Observation Chart. The observations are often recorded by unqualified Health Care Assistants but the recordings should be checked and interpreted by a qualified nurse A trigger score is given for each set of observations; one trigger should result in a review by a senior nurse and an increase in the frequency of observations, two triggers requires a review by a doctor and three triggers a review by a specialist registrar. The chart is a tool to ensure that there is an escalation of care t0 an appropriate level: (2) In the case of Mr: White the EWS chart was not completed correctly, triggers were ignored and none of the observations were checked by a qualified member of staff_The evidence of Dr.

an independent expert was This resulted in lost opportunities to reassess Mr. White and in place the necessary resuscitative measures_ (3) was also told that there is no regular audit system in place to ensure that the charts are correctly completed, interpreted acted upon.