Akash Bhudia

“The Xray on the 28 February 2022, which was carried out following treatment for pneumonia, showed an obvious progression in lung consolidation and was highly suggestive of tuberculosis (a new clinical diagnosis). [the deceased] was not an in-patient in hospital at the time of the follow-up Xray. He had been discharged and was therefore not under the active management of a clinical team. The inquest heard that such significant, unexpected, and important changes should have been highlighted to the referring”