“Prophylactic antibiotics for severely immunocompromised patients: The inquest 5 heard…”

The coroner’s concerns

– 1. Prophylactic antibiotics for severely immunocompromised patients: The inquest 5 heard evidence that patients like Aarav who are immunocompromised require additional prophylactic antibiotics for procedures. This is not covered in the current NICE guidelines. My concern is that there is currently no guidance for the use of prophylactic antibiotics in severely immunocompromised patients. 2. Experience and competence of trainees: The inquest heard evidence that there was confusion around the experience and level of the trainee involved. He was thought to be an ST6 when he was an ST4. My concern is that there is no mechanism to evidence trainees experience and competence when they travel to various different hospital trusts as part of their training. 3. Consent forms: The parents of Aarav were unaware that a trainee would be doing the liver biopsy. My concern is that there is currently no way to obtain consent when a trainee will be doing the procedure. 4. Individual patient risk factors: Aarav had a complex medical background and several risk factors for any procedure. My concern is that there is currently no mechanism to identify individual patient’s risk factors so that all clinicians involved in their care are aware. 5. Learning from deaths: The initial M&M meeting after Aarav's death was described as inadequate. My concern is that there was no immediate learning from this tragedy and further consideration is needed to ensure a safe and effective mechanism to properly learn from deaths at the earliest opportunity. 6. Electronic patient records: I heard evidence that the lack of electric medical records meant clinicians found it difficult to see all of the patient’s medication details. My concern is that critical information can be missed if clinicians do not have access to all the clinical records when planning treatment.

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, 2025-0019

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