Source · Prevention of Future Deaths
Stephanie Marks
Ref: 2016-0233
Date: 20 Jun 2016
Coroner: S Fox QC
Area: Avon
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner noted a lack of evidence that staff checked daily if all GP messages had been countersigned as received or acted upon by the GPs.
Date
20 Jun 2016
56-day deadline
15 Aug 2016 est.
estimated from the report date
Responses identified
0 of 1
Coroner's concerns
The coroner noted a lack of evidence that staff checked daily if all GP messages had been countersigned as received or acted upon by the GPs.
View full coroner's concerns
_ There was no evidence that staff check at 6.3Opm each that all GP messages have been countersigned as receivedlacted on by the GP'$, for that day.
Report sections
Investigation and inquest
On 11"h August 2015 an investigation commenced into the death of Stephanie Louise MARKS, Aged 18. The investigation concluded at the end of the inquest on zuguste June 2016. The conclusion was that the medical cause of death was Ia Sudden cardiac death in a setting of anorexia nervosa and hypokalaemia and the conclusion as to the death was a narrative that read: Miss Marks died from the consequences of untreated hypokalaemia_ CIRCUMSTANCES @F THE DEATH Miss Marks died from untreated hypokalaemia which had been reported to the practice on 31.7.15_ Systems for passing blood results to GP's at that time were inconsistent. Certain improvements in these have been made since Miss Marks' death.
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_
Similar PFD reports
Report details
- Reference
- 2016-0233
- Date of report
- 20 June 2016
- Coroner
- S Fox QC
- Coroner area
- Avon
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: 15 Aug 2016 (estimated from the report date).
Sent to
- Clevedon Medical Centre