Keith Hill

“When the plan changed and the transjugular liver biopsy became a percutaneous one, there was no communication between the interventional radiologist and the hepatologists. Even if it had not changed the plan, Mr [name redacted] management would have benefited from a robust discussion between the specialists in these two fields, and an accurate record of the decision making.”

“Mr [name redacted] medical records were at times inadequate. The microbiologists thought that the junior hepatologists were making a record and vice versa. In the event, neither did. Most specifically, following the repeated advice of the microbiologists, the decision to change the plan and to prescribe micafungin on 25 June was not documented, it was simply written up on the prescription chart.”

“The junior pharmacist charged with dispensing the micafungin on the evening of 25 June recognised its toxicity to the liver and could not see from the medical record that Mr [name redacted] liver function tests and hepatitis had been taken into account in the prescription. The last relevant entry in the medical record indicated that the micafungin should be held off.”