Source · Prevention of Future Deaths
Naiya Diarra
Ref: 2023-0412
Date: 7 Oct 2015
Coroner: Richard Brittain
Area: Inner North London
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryRelevant patient information was stored in disparate record systems, making it difficult for clinicians, especially psychiatric teams, to access critical details. The coroner noted this poses risks due to the current state of record sharing within the NHS.
Date
7 Oct 2015
56-day deadline
2 Dec 2015
stated in the report
Responses identified
0 of 1
Coroner's concerns
Relevant patient information was stored in disparate record systems, making it difficult for clinicians, especially psychiatric teams, to access critical details. The coroner noted this poses risks due to the current state of record sharing within the NHS.
View full coroner's concerns
(1) Multiple pieces of relevant information regarding current illness were contained in disparate record ‘silos’. It was difficult for clinicians to access this information and, as such, it was not available to the reviewing psychiatric team, in particular. I am concerned that the previous focus on access to medical records, which was to occur through the NHS Programme for IT, has been lost and that the new focus on patient access to GP records will not address the risks posed by the current state of record sharing within the NHS.
Report sections
Investigation and inquest
Naiya Diarra died on 25 June 2015, aged 9 months old, from dilated cardiomyopathy, arising from severe Vitamin D deficiency. An inquest into her death was heard on 30 October 2015, at which I recorded a narrative conclusion (see attached).
Circumstances of the death
Naiya was not known to have developed the severe Vitamin D deficiency, from which she ultimately died. I heard evidence that vitamin supplementation was discussed with her mother and instituted through her mother taking additional dietary vitamins and later through use of additional formula feeding. However, it is clear that this was ultimately insufficient to prevent her death. Her sibling was known to be Vitamin D deficient and I saw evidence that health visitors had attended the family home regarding this and had given advice regarding sunlight exposure in particular. However, the significance of her sibling’s deficiency was not recognised by those treating Naiya and I concluded that there was missed opportunities to address this. I heard evidence that NICE guidance exists regarding the identification and treatment of Vitamin D deficiency
Copies sent to
GP and the three NHS Trusts involved
Similar PFD reports
Report details
- Reference
- 2023-0412
- Date of report
- 7 October 2015
- Coroner
- Richard Brittain
- Coroner area
- Inner North London
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 2 Dec 2015 (stated in the report).
Sent to
- National Institute for Health Care Excellence