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recurance

Jamie Poole

15 Mar 2021 · Coroner Emma Serrano · Stoke-on-Trent & North Staffordshire Coroner's Court

The coroner's concerns

  1. 1. inadequate monitoring of post-transplant magnesium levels

    “Transplant patients are put on strong immunosuppressive medication to prevent rejection of the transplanted organ. The medication, tacrolimus in [name redacted] case, has a common known side effect of reducing magnesium levels within the body. This can be life threatening. Despite this, it is not standard practice to regularly test transplant patients magnesium levels. I heard evidence at inquest that, whilst the Trust providing care for [the deceased] [name redacted], has now remedied this, and routinely test”

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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