“arte as follows”

The coroner’s concerns

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arte as follows. - 1. The finding of a high globulin by a laboratory from a blood test in A&E was not followed up by either the laboratory or AGE department. It was not in College guidelines of tests which required urgent notification. It was indicative of a fatal disease, which was not diagnosed for approximately another 4 months. I accept the professional opinion of the haematologist that this was a system failure, which is not acknowledged by the Trust. The laboratory suggested an additional action to have an automated comment but that would still not deal with the problem of reports returning to physicians in secondary care. Evidence was heard that there is inconsistency in laboratory repeating and alerting of clinicians even between hospitals in the jurisdiction, and insufficient evidence of a safe system within the Trust. 2. The expert pharmaceutical physician gave a recommendation that the need for cardiac monitoring was made more definitive in the drug prescribing information for Carfilzomid (and possibly others), which was prescribed in the Cardamon Trial.

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, 2019-0479

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