David Mountain
24 Dec 2014 · Coroner Jacqueline Lake · Norfolk
The coroner's concerns
1. delayed investigation of bleeding and vascular damage
“Despite having had a permanent pacemaker inserted on 20 June 2014 and Mr [name redacted] developing chest pain on 21 June 2014, the risks recognised on the consent form, including risk of bleeding and vascular damage were not fully investigated and an Echocardiagram was not performed until afternoon of 23 June 2014. The results, which showed a mild to moderate bleed around the heart, were not available until after Mr [name redacted] death.”