Professor Fiona J Wilcox, Senior Coroner for Inner West London, noted that crucial delay in treatment due to staff shortages led to Mr Powell's death, stating, "Had Mr Powell’s blood flow been restored on September 4, he likely would not have died." The report emphasized the avoidable nature of this tragedy, attributing it to systemic failures in emergency care prioritization and staffing issues that delayed urgent evaluations.
Coroner Wilcox detailed the series of unfortunate events: "Mr Powell presented with severe symptoms, yet a five-hour delay before adequate medical review substantially worsened his condition. The lack of timely intervention for restoring blood flow was a critical factor in his deteriorating health, which led straight to his preventable death." This highlights serious concerns about hospital resource management.
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