Lynda Pedersen

“[the deceased] was admitted to William Harvey Hospital on 6th September 2017 with dysphagia. A gastroscopy conducted two days later identified a stricture within the oesophagus with the appearance of the mucosa suggestive of a submucosal infiltration. A CT scan did not identify a malignancy but indicated that the area of concern could not be evaluated as it had not been distended by the orally ingested contrast. [the deceased] had a number of further gastroscopies to attempt to dilate her oesoph”

“Fluid balance charts were not correctly completed in the period leading to [the deceased]'s death. The evidence from the fluid balance charts showed that she was carrying fluids forward until the time of her death; there being an imbalance to the tune of some 3 1/2 litres. That there was a significant fluid overload was also evident from the pathology. That she had a fluid overload was only identified by the hospital at a time that she was temporally close to death. It was accepted at the inquest”