Edward Hearn
8 May 2019 · Coroner Andrew Harris · London Inner (South)
The coroner's concerns
1. failure to follow up abnormal blood test results leading to delayed diagnosis of fatal disease
“The finding of a high globulin by a laboratory from a blood test in AGE was not followed up by either the laboratory or A&E 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 auto”
2. inadequate cardiac monitoring for patients receiving chemotherapy
“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”