Ashana Charles
11 Dec 2025 · Coroner Andrew Harris · South London
The coroner's concerns
1. underreported deaths associated with IV feeding
“deaths that might be associated with IV feeding were probably underreported due to inadequate investigation”
2. inconsistent guidance on filter use in parenteral feeding
“inconsistency at the time between US and European and UK guidance about use of filters in parenteral feeding (PN)”
3. non-standard 1.2 micron filter use in IV feeding
“use of 1.2 micron filter at the time was not standard practice, perhaps because of cost or operational reasons as the filter often led to blockages and delays in IV feeding”
4. delayed governance review of 1.2 micron filter use
“Lewisham & Greenwich NHS Trust have begun to re-evaluate the use of 1.2 micron filters in PN feeding but the matter had not yet gone to its governance department but should do so next year”
5. inadequate safety assurance of PN product checks
“Uncertainty whether the reported visual checks of PN products by batch rather than individually provided adequate safety assurance”