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recurance

Karen Jane Winn

22 Oct 2020 · Coroner Nigel Parsley · Suffolk

The coroner's concerns

  1. 1. lack of escalation to haematology specialist

    “I am concerned that a differential diagnosis of a rare and serious blood condition (haemolytic anaemia), although identified soon after admission, was not escalated to a Haematology Consultant at the time this diagnosis was made”
  2. 2. automated VTE assessment system robustness

    “I am concerned that the automated VTE assessment system does not appear to be significantly robust”
  3. 3. lack of flagging for prophylactic anticoagulation

    “I am further concerned that if a consultant at an early review has decided that prophylactic anticoagulation medication needs to be administered (even in the situation when a INR test is still awaited) that this is not clearly flagged on the patient electronic record in the Smart Zone”

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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