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recurance

Lita Serkes

16 Dec 2016 · Coroner ME Hassell · London Inner (North)

The coroner's concerns

  1. 1. delayed recognition of stroke

    “The Whipps Cross medical notes record normal observations, most specifically that Mrs [name redacted] was”
  2. 2. misdiagnosis of stroke timing

    “When Mrs [name redacted]' treating consultant gynaecological surgeon attended her at 10.30am on Saturday, 23 July, he formed the impression that he was the first person to diagnose the stroke”
  3. 3. unnecessary delay in transfer to specialist care

    “The decision was made by, at the latest 10.30am, but quite possibly an hour before then, to transfer Mrs [name redacted] to the Royal London Hospital for specialist care, but transfer was not effected until 2.07pm”
  4. 4. inadequate pain management due to unconnected device

    “Patient controlled administration of pain relief was arranged for Mrs [name redacted], but she remained in pain. It was quite some time before it was recognised that the device was not connected and so was not delivering any analgesia”
  5. 5. failure to document surgical assessment

    “Mrs [name redacted]' surgeon went to the Royal London Hospital to see her at 10.30pm on Saturday, 23 July. He described in court palpating her abdomen and there being no rigidity, guarding, or further distension. However, he made no record in the medical notes of his attendance and examination”
  6. 6. misinterpretation of imaging results

    “The same surgeon described in court his view that [static] imaging did not disclose any active bleeding and so there was no indication to return to theatre”

Responses

2016-0458-Response-by-Barts-Health-NHS-Trust.pdf ↗· Royal London Hospital

Stated action · 01 April 2017

“The Trust recognises that stroke is an emergency and that you feel there was inadequate urgency in managing Mrs [name redacted] stroke. As a result the Trust is currently in the process of reviewing the hospital policy for the management of stroke and is also reviewing the checklist of advice given by the Hyperacute Stroke Unit. The Trust is hoping that this will be completed by 01 April 2017.”
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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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