“is as follows”
Dated 9 May 2014, from the coroner for Inner South London. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedOrganisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated9 May 2014
- Published on judiciary.uk5 May 2014
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Responses from each recipient
| Sent to | Response |
|---|---|
| King's College Hospital NHS Foundation TrustNamed in the report as “Kings College Hospital NHS Foundation Trust” | Response publishedPublished on judiciary.uk in May 2014. |
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The coroner’s concerns
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is as follows. — (1) The 3+ proteinuria discovered in A&E was not communicated to the ward. (2) The Trust failed to communicate the significance of the persistently raised ESR and CK to the patient and family. (3) The Trust failed to send the GP a discharge summary or communicate to the surgery the significance of the raised ESR and CK and the need for further monitoring. (4) Despite the exceptionally high ESR, elevated CK of which no cause was found and proteinuria, a diagnosis of cellulitis was preferred to that of a connective tissue disorder. The opportunity to treat her SLE was missed due to failure to diagnose the condition, whilst recognizing that diagnosis was hampered by her self discharge. (5) Before discharge neither the patient nor the imminent self discharge were not known to the consultant, who would have wished to be informed and would have sought further investigations and communications (6) Concerns (2) (3) and (5) above were not considered by the Serious Untoward Incident Investigation by the Trust.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2014-0209
- Added to Minute Book
- 8 Oct 2026
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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