The inquest revealed significant failures in the care provided to Chloe Every, including inappropriate prescriptions and lack of necessary communication support, contributing to her death.
Chloe Every's inquest highlighted the absence of specialist learning disability nurses, which compounded her vulnerability and led to her receiving potentially harmful treatments without consent.
The coroner noted that the hospital staff's repeated failure to adhere to guidance underscored a systemic issue in care, culminating in Chloe's tragic demise.
Despite individual failures not reaching the threshold of gross negligence, the cumulative effect of hospital staff's actions constituted a significant breach of care standards.
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