Shre Chatterjee

On 03 November 2023 I commenced an investigation into the death of Shre Kumar CHATTERJEE aged 44. The investigation concluded at the end of the inquest on 29 September 2025. The conclusion of the inquest was that: On 03 November 2023 I commenced an investigation into the death of Shre Kumar CHATTERJEE aged 44. The investigation concluded at the end of the inquest on 29 September 2025. The conclusion of the inquest was that: In mid-August 2023 Shre Chatterjee, aged 44, suffered a subdural haemorrhage, a rare type of brain bleed for someone of his age. He and his wife attempted unsuccessfully to get treatment for this on many occasions over the next 8 weeks. He sadly died at University Hospital on 12th October 2023. When by 25th September Shre Chatterjee described worsening Red Flag symptoms such as visual disturbance there was a missed opportunity to refer him to A &E for a CT scan. Again, on the 1st of October when, in addition to his other symptoms, he reported memory loss there was a further missed opportunity to refer him to A &E for a CT Scan. There was a final window closed to him in the early hours of 10th October when the ambulance crew did not convey him to hospital. Had he been taken to hospital on 25th September or 1st October a CT scan would have been arranged, surgery performed and on balance it is likely he would have survived. The short time frame on 10th October may make this less likely

On about 14th August 2023 Shre Chatterjee aged 44 developed a sudden  and severe headache. He sought diagnosis and treatment on multiple occasions. 16.08 23-UCC seen by a Dr-Examination-H/ache 2 days aching over the neck -probable frontal sinusitis 18.08.23-UCC seen by Advance Care Practitioner-Examination-sinusitis but prescribed different medication 23.08.23-UCC seen by a 2nd Dr-Examination-Tension Headache as pain on palpation of neck-diazepam 3 days to relax neck and Amitriptyline 04.09.23-  Shre sent an E mail to his named GP at Forestside-appointment booked 6th October 21.09.23-Waterside Physiotherapy & Osteopathy Clinic-1st attendance-soft tissue massage /spinal mobilisation-better movement /pain remained 25.09.23-111  Call-blurred vision 2 weeks-contact local services 2 hours (told him needed to see GP) 25.09.23-PHL OOH GP -Telephone Call -severe pain post osteopath but later pain the same, not able to take son to work because could not drive-no blurred vision mentioned in GP record-advice  contact GP 24 hours (local service ) urged him to see GP asap 28.09.23-  2nd attendance Waterside Physiotherapy & Osteopathy Clinic-Acupuncture 01.10.23-111 call – Healthcare Worker recorded headache, memory loss, blurry vision and sleeping much more than usual – referred him for a clinical call back in 1 hour 01.10.23-111/OOH Dr-headache ,memory loss, blurry vision, cannot work-?referred neck pain /tension headache – needs a scan to reassure – Revalidation-contact local service 24 hrs 05.10.23-Diabetic Retinopathy Review UHS-NAD 06.10.23-GP appointment cancelled due to GP sickness rescheduled for 10th October 10.10.23-breathless-wife called ambulance-111/SCAS 02:54-Chasing ambulance 10.10.23-SCAS 1st attendance 04:04-reassured by 10am appointment with GP ? MSK pain/Migraine? Worsening advice 10.10.23-Telephone Appointment 10am -Dr Ellen Neale spoke to wife as patient was asleep -referral to Neurology, letter same day 10.10.23-SCAS 2nd attendance 15:44-GCS3 + Pt had vomited -transferred to hospital 10.10.23-  UHS ED after patient found unresponsive at home. CT imaging revealed an Acute on Chronic Subdural Haematoma 12.10.23-Shre Chatterjee sadly died at University Hospital Southampton due to an Acute on Chronic Subdural Haematoma.