“That when a diagnosis of severe hypokalaemia is made in patients that there is the…”
Dated 19 Mar 2016, from the coroner for Derbyshire. 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
Deadline passedReplies were due by 14 May 2016. A reply may have been sent and not yet published.
Organisations 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.
- Report dated19 Mar 2016
- Deadline14 May 2016
- Published on judiciary.uk19 Mar 2016
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Chesterfield Royal Hospital NHS Foundation Trust | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 14 May 2016. A reply may have been sent and not yet published. |
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
- (1) That when a diagnosis of severe hypokalaemia is made in patients that there is the monitoring of potassium levels every 8 hours and adherence to the Trust Management of acute hypokalaemia guidance. This is particularly important as the guidance itself makes clear “ECG changes can occur at any level of hypokalaemia. Hypokalaemia can result in flat T waves, ST depression, QT interval prolongation and prominent U waves. Ventricular arrhythmias (eg torsades de pointes, ventricular tachycardia and ventricular fibrillation) can also occur. It is of concern that this monitoring did not take place during the last admission of Ann Jacobs and by way of treatment for her identified severe hypokalaemia.
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, 2016-0111
- 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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