Johanna Moreland

“Results from lumbar puncture taken on 26th February 2021 were made available on 4th March 2021. Evidence heard at the inquest was that Lumbar Puncture tests are usually for diagnosis of serious illness and would usually be made available within 24- 48 hours”

“The Lumbar Puncture results were positive for encephalitis and in the absence of the tests results, a liver biopsy was conducted and, there was a delay in antiviral treatment commencing.”

“The Trust policy on the required levels of observations following a liver biopsy were not followed on return to the ward due to a miscommunication between Trust staff and the required levels of observations was not recorded in the medical records.”