Abiola Dosunmu
9 May 2014 · Coroner Andrew Walker · London (Inner South)
The coroner's concerns
1. 3+ proteinuria not communicated to ward
“The 3+ proteinuria discovered in A&E was not communicated to the ward.”
2. lack of communication about raised ESR and CK significance
“The Trust failed to communicate the significance of the persistently raised ESR and CK to the patient and family.”
3. lack of discharge summary and communication to GP
“The Trust failed to send the GP a discharge summary or communicate to the surgery the significance of the raised ESR and CK and the need for further monitoring.”
4. missed diagnosis of SLE due to preferred cellulitis diagnosis
“Despite the exceptionally high ESR, elevated CK of which no cause was found and proteinuria, a diagnosis of cellulitis was preferred to that of a connective tissue disorder. The opportunity to treat her SLE was missed due to failure to diagnose the condition, whiist recognizing that diagnosis was hampered by her self discharge.”
5. lack of awareness of imminent self discharge by consultant
“Before discharge neither the patient nor the imminent self discharge were not known to the consultant, who wouid have wished to be informed and would have sought further investigations and communications”