Barbara Cope
8 Jun 2026 · Coroner Louise Slater · South Yorkshire (West)
The coroner's concerns
1. delayed administration of N-Acetylcysteine
“there was no evidence of communication and/or follow up of the abnormal result, therefore time critical medication was not commenced until 19 hours later”
2. delayed or omitted medical management
“If clinical records and recent investigations results are not reviewed then appropriate medical management will be delayed or will not occur”
3. unclear responsibility for patient care
“There needs to be clear communication, understanding and record keeping of who is responsible for patient and the ongoing follow up and care in these circumstances”