“The clinical decision was made that she needed further investigation on 16th February…”

The coroner’s concerns

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- The clinical decision was made that she needed further investigation on 16th February (contrast CT scan, MRI scan), that would lead to further tests to diagnose the cause of her cerebral lesions. She declined admission but was agreeable to have the investigations as an outpatient. This never happened. There are four matters in the circumstances which cause concern 1. The doctor who ordered the scan did not conduct any follow up to see that it had been performed. The consultant chest physician said that handover of care was dangerous time and that it was his duty to do so. 2. The referring doctor notified the GSTT community palliative care team of the need to organize a MRI scan, on the understanding that the team was taking over care, The consultant in the palliative care team explained that their role was to advise the doctor responsible for care, which was at the time, the general practitioner. The referring doctor did not inform the general practitioner 3. The discharge note to the GP from the A&E indicated a diagnosis of stroke (presumed before CT scan), did not mention the CT finding of cerebral lesions that may be metastases, nor the need for EMI scan and further investigation to conform diagnosis, nor the booking of a MRI scan 4. A member of the palliative care team rang the AGE department and was told that the scan appointment was the next day (17th). When the patient and her mother attended the next day, she was told that there was no appointment. Evidence was heard that the booking, which was on the basis of being an in- patient, is automatically cancelled if the patient becomes an out-patient and the clinical referral cannot be transferred to an outpatient appointment. A new referral and form needed to be completed. So the patient went home, and no further appointment was made. The above evidence suggests a system failure in handover of patients who leave A&E with the need for urgent follow up. ACTION SHOULD BE TAKEN Evidence was heard of IT links between the hospital and general practice being launched, but in my opinion, it is not clear that alone that will adequately mitigate the risk of other deaths, and KCH is in the position to consider if any further steps need to be taken. It is copied to GSTT, as the cooperation of that Trust may be necessary.

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, 2017-0201

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