Source · Prevention of Future Deaths
Caroline Lee
Ref: 2013-0228
Date: 11 Sep 2013
Coroner: S McGovern
Area: Coventry
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner identified a lack of recognition by medical staff regarding the significance of potassium results and insufficient communication from the laboratory to ward staff about abnormal results.
Date
11 Sep 2013
56-day deadline
6 Oct 2013
stated in the report
Responses identified
0 of 1
Coroner's concerns
The coroner identified a lack of recognition by medical staff regarding the significance of potassium results and insufficient communication from the laboratory to ward staff about abnormal results.
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:
Similar PFD reports
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 (stated in the report).
Sent to
- University Hospital Coventry and Warwickshire