Bryan Whitby
25 Mar 2015 · Coroner Joanne Kearsley · Manchester (South)
The coroner's concerns
1. lack of awareness of scan date and CKD stage 3
“The deceased had been unwell for some time and had a history of Chronic Kidney Disease Stage 3. He had been referred for a CT scan but the GP Practice were not aware of the date of the scan or that this would take place on the 3rd May.”
2. failure to escalate blood test results and radiologist lacked access to recent results
“Blood tests taken on the 2nd May were not escalated by the GP or the pathology laboratory and the scan on the 3rd May went ahead whilst he was still receiving metformin medication. The radiologist carrying out the scan did not have access to his blood results from the 2nd May and simply went off the results from the GP referral some time ago.”
3. unclear responsibility for ordering further blood tests
“There is no record of who requested further blood tests on the 6th May.”
4. lack of escalation of critical blood test results
“The results of the blood tests on the 6th May should have resulted in urgent discussion with the deceased's GP or the deceased himself. There was no escalation of these results by the biochemistry laboratory.”
5. delayed emergency admission despite critical blood results
“Despite the blood results, the deceased was not admitted to hospital as an emergency and there was a delay in recognising the seriousness of these results.”
6. failure to recognise and treat serious condition upon admission
“When he was admitted into hospital there was a failure by the treating medical staff to recognise his serious medical condition and then a failure to carry out the required medical treatment.”