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Sidney Alexander

Ref: 2016-0257 Date: 18 Jul 2016 Coroner: PS Cooper Area: Lincolnshire (South) Responses identified: 0 / 1 View PDF

Biopsy reports lacked sufficient space for consultants to fully complete their findings, resulting in incomplete and potentially inadequate medical documentation.

Date 18 Jul 2016
56-day deadline 12 Sep 2016 est.
Responses identified 0 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
Biopsy reports lacked sufficient space for consultants to fully complete their findings, resulting in incomplete and potentially inadequate medical documentation.
View full coroner's concerns
Consultant Gastroenterologist gave evidence, During that evidence he conceded that he hadntt been able to fully complete a Biopsy report for Unilabs as there was insufficient room on it: Surely a form can be expanded or provision made for an addendum?

Report sections

Investigation and inquest
On 12/06/2015 commenced an investigation into the death of Sidney Brian Alexander, age 73. The investigation concluded at the end of the inquest on 01/06/2016. The conclusion of the inquest was a Narrative Conclusion (attached)
Circumstances of the death
Mr Alexander was admitted at 06.30hrs on 19/05/2015 with a background of 1997 cardiac transplant (on immunosuppressants) , COPD an colitis He presented with a few months history of diarrhoea_ Treated medically for Crohn's exacerbation with IV steroids and then infliximab to no effect. He developed respiratory distress on 03/06/2015. X-Ray showed diffuse right sided infiltrates_ CMV positive Treated with Memperom and Ganciclovir but Mr Alexander died at 2310hrs in the Pilgrim Hospital, Fishtoft. Unit 1, Gilbert Drive; Endeavour Park, Boston PE21 7TQ Tel: 01522 553374 Fax: 01522 516717 Email: HMCoroner_Southlincolnshire@lincolnshire gov.uk

P $ Cooper Her Majesty's Acting_Senior Coroner for South Lincolnshire
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you andlor your organisation have the power to take such action:

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Report details

Reference
2016-0257
Date of report
18 July 2016
Coroner
PS Cooper
Coroner area
Lincolnshire (South)

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: 12 Sep 2016 (estimated).

Sent to

United Lincolnshire Hospitals NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.