Bernard Fagg

On 21st December 2017 an inquest concerning the death of BERNARD JOHN FAGG was opened. I resumed and concluded the inquest on 17th 2018. The conclusion of the inquest was that Bernard John Fagg died following necessary medical procedure:

Bernard John Fagg was admitted to hospital on 5/12/17. He had been referred by his GP on that due to concerns as to breathlessness Following admission the working diagnosis was of heart failure, anaemia, fast atrial fibrillation and interstitial lung disease possibly asbestos related: There was a history of weight loss. The combination of this with the shortness of breath and anaemia led the clinicians to seek a CT May day scan of the chest: Mr Fagg had a CT scan with contrast (chest) on 7/12/17. His renal function was normal and at that stage there were no indications of any kidney problems: The decision to proceed to a CT scan with contrast was entirely appropriate Renal function was normal on 8/12/17. An endoscopy had also been requested and this took place on 8/12/17. An endoscopy was entirely necessary in the circumstances of the presentation: The procedure necessarily required the patient be nil by mouth for a number of hours The patient was stable until 10/12/17 when he developed acute kidney injury: The working diagnosis and indeed cause of death as given by the clinicians was acute kidney injury (non-traumatic) due to contrast induced nephropathy. He was not deemed suitable for dialysis and later died on 14/12/17. Although it is acknowledged that there is an ongoing debate as to whether the contrast presents a risk to kidney function, having regard to the absence of any other factors this was the most likely cause of the kidney injury in this case:

Consideration as to whether any form of policy or guidance is required to alert clinicians to the fact that when following a CT scan with contrast, a patient is to be nil by mouth for a period of time (for the purposes if other medical procedures) the patient should be considered for intravenous fluids.