Source · Prevention of Future Deaths

Andrea Franzosi

Ref: 2018-0314 Date: 25 Oct 2018 Coroner: Katy Skerrett Area: Gloucestershire Responses identified: 0 / 1 View PDF

Inadequate supervision of junior doctors on wards, specifically regarding patient discharges occurring without examination by a senior practitioner.

Date 25 Oct 2018
56-day deadline 20 Apr 2019 est.
Responses identified 0 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
Inadequate supervision of junior doctors on wards, specifically regarding patient discharges occurring without examination by a senior practitioner.
View full coroner's concerns
(1) The level of supervision of junior Doctors on the ward. In particular; when a patient is discharged without examined by a more senior practitioner:

Report sections

Investigation and inquest
On the 13th November 2017 commenced an investigation into the death of Andrea Franzosi. The investigation concluded at the end of the inquest on the 24"h October 2018. The conclusion of the inquest was a narrative conclusion: The medical cause of death was 1A Cardiac failure 1B Necrotising Aortic Valve Endocarditis, Chronic Obstructive Pulmonary Disease and Emphysema
Circumstances of the death
Mr Franzosi, was a 52 year old man who presented to the Emergency Department at hospital on the 8" November 2017 with "flu-like" symptoms which he reported experiencing for two weeks. He had also suffered three episodes of central chest pain which was associated with shortness of breath. Mr Franzosi was diagnosed with pneumonia and discharged home on oral antibiotics He was not admitted for further investigations. As a result his endocarditis was not diagnosed, and he did not receive treatment for this condition. This amounted to neglect which contributed to cause of death. At approximately 11.21 hours on gth November 2017 Mr Franzosi collapsed whilst out with friend: Emergency services attended and despite extensive resuscitation efforts, Mr Franzosi was pronounced deceased at 13.55 hours_
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action. Gloucestershire Coroner's Court, Corinium Avenue, Barnwood, Gloucester, GL4 3DJ Tel 01452 305661 coroner@gloucestershire gov.uk the the being

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Report details

Reference
2018-0314
Date of report
25 October 2018
Coroner
Katy Skerrett
Coroner area
Gloucestershire

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: 20 Apr 2019 (estimated).

Sent to

Gloucestershire NHS Trust

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