Graeme Irvine, the senior coroner, emphasized that the inquest into Chloe Every’s death revealed significant lapses in hospital care that could risk future lives.
Chloe Every suffered a cardiac arrest following her admission, with her family highlighting that she died in pain and agitation due to inadequate care.
The inquest revealed that vulnerable patient care failed due to inappropriate prescriptions, lack of specialist staff, and questionable medical procedures without consent.
Irvine raised concerns that the absence of contemporary medical records obstructed the identification of staff responsible for critical decisions during Every's treatment.
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