Source · Prevention of Future Deaths

Vijay Sonagara

Ref: 2014-0364 Date: 7 Aug 2014 Coroner: Philip Barlow Area: London (South Inner) Responses identified: 0 / 1 View PDF

Critical medical information was not consolidated, as the patient had multiple unamalgamated records and a temporary file, leading to treating doctors being unaware of potentially relevant history.

Date 7 Aug 2014
56-day deadline 3 Oct 2014
Responses identified 0 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
Critical medical information was not consolidated, as the patient had multiple unamalgamated records and a temporary file, leading to treating doctors being unaware of potentially relevant history.
View full coroner's concerns
The evidence at the inquest was that Mr Sonagara was being seen by the gastroenterologists at Whipps Cross Hospital at the same time as he was considered for surgery byb However; the gastroenterology treatment was recorded in a different set of hospital records using a different hospilal number (but under the same name, same address, and same NHS number). In addition the evidence showed that there was a temporary file containing further medical records. These sets of medical records were not amalgamated or cross referenced. and his team were unaware of the other medical records and the information contained within them_ As a result they were unaware that Mr Sonagara was being actively investigated at the same hospital: The information within the second and third set of records was potentially relevant to the decision making_although my final conclusion was that it would not have being altered the decision t0 operate in this case. My concerns are therefore as follows: (1) Mr Sonagara had two different sets of medical records under two different hospital numbers that were not amalgamated or cross referenced_ (2) In addition a third temporary file of medical records was not incorporated into the permanent file, (3) Potentially relevant information contained in the second and third set of records was available to Mr Sonagara's treating doctors _

Report sections

Investigation and inquest
On 27 February 2013 commenced an investigation into the death of Vijay Sonagara, age 54. The investigation concluded at the end of the inquest on 6 August 2014. The conclusion of the inquest was misadventure. The medical cause of death was Ia multi-organ fallure; 1b alcoholic cirrhosis of the liver complicated by surgery for inguinal hernia repair (operated 8.2.13).
Circumstances of the death
Mr Sonagara had alcoholic liver disease and on 8 February 2013 underwent routine surgery for repair of inguinal hernia at Whipps Cross Hospital under the care of On 11 February 2013 Mr Sonagara's condition deteriorated rapidly: He was found to have decompensated alcoholic liver disease requiring intensive care treatment_ He was transferred to St Thomas' Hospital where_he died on 22 February 2013
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
2014-0364
Date of report
7 August 2014
Coroner
Philip Barlow
Coroner area
London (South Inner)

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: 3 Oct 2014.

Sent to

Barts Health NHS Trust

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