Lee Bates
17 Sept 2015 · Coroner Andrew Harris · London Inner (South)
The coroner's concerns
1. use of CPAP machine without specialist guidance
“neither the psychiatrists sought advice from the sleep apnoea clinic nor did the clinic inform the psychiatrists of the importance of using CPAP, the risks of not doing so and the ri ive medication especially if not using it and the desirability of cnet lll of the hospital”
2. avoidable death in OSA patients with morbid obesity
“there is an on going risk of avoidable death in patients with OSA in Cambian Churchill hospital (especially if severe and associated with morbid obesity)”
3. absence of structured communication between specialists and psychiatrists
“Neither hospital has addressed how this dialogue is to be instigated when required, nor how these risks shouid be addressed; reliance on GP advice seeming to be insufficient”