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Caroline Lee

Ref: 2013-0228 Date: 11 Sep 2013 Coroner: S McGovern Area: Coventry Responses identified: 0 / 1 View PDF

Medical staff failed to recognise the significance of abnormal potassium results, compounded by the laboratory's failure to inform ward staff promptly, hindering timely intervention.

Date 11 Sep 2013
56-day deadline 6 Oct 2013
Responses identified 0 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
Medical staff failed to recognise the significance of abnormal potassium results, compounded by the laboratory's failure to inform ward staff promptly, hindering timely intervention.
View full coroner's concerns
_ failure of the medical staff to recognise the significance of the potassium results (2) failure of the laboratory to inform the Ward staff of the abnormal potassium results

Report sections

Investigation and inquest
On 24 June 2013 commenced an investigation into the death of Caroline LEE 49 years old. investigation concluded at the end of the inquest on 11 September 2013. The conclusion of the inquest was a Narrative Verdict (Copy attached)
Circumstances of the death
See Narrative Verdict
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you as Chief Executive of the Trust have the power to take such action:

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Report details

Reference
2013-0228
Date of report
11 September 2013
Coroner
S McGovern
Coroner area
Coventry

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: 6 Oct 2013.

Sent to

University Hospital Coventry and Warwickshire

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.