Leslie Harding

“Patients with a suspected life-threatening condition (Pulmonary Embolus) must be promptly treated. The system for ensuring that the treatment is provided must be robust. That is particularly the case where it is already known that the patient suffers from an underlying condition that makes him prone to the particular life-threatening event.”

“Your practice will have a number of other patients in receipt of anti- coagulation treatment following recurrent Pulmonary Embolii. Given the omission that appears to have occurred here, you need to ensure that no other omissions have happened with any of the other patients”

“At Inquest, I gained the impression that Lez was felt to be non- compliant with his anti-coagulation regime. It was plain from the prescription history that there were repeated gaps in the provision of medication that Lez required. There seemed, however, in my view, to have been little effort given to addressing the reasons why, or indeed if, Lez actually was non-compliant with his medication.”

“I was advised that this death had not yet been reviewed in a significant events meeting. In my view, that should have taken place forthwith after Lez's death.”