Sarah Chappell
7 Dec 2023 · Coroner Stephen Simblet · Inner North London
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. delayed transfer of patient
“There was a ten day delay in Ms [name redacted] transfer from the Princess Royal Hospital to UCLH”
2. inappropriate clinical responsibility
“the consultant urology surgeon in charge of Ms [name redacted] care was very firmly of the view that he was not the best clinician to fulfil this role”
3. failure to transfer care
“Despite the agreement on 16 June of the gastroenterology clinical director that Ms [name redacted] care should be led by the gastroenterologists, they had not taken over her care by the time of her death,”
4. misunderstanding of acute condition
“There was a frequent misunderstanding among the medical staff that Ms [name redacted] issues were all chronic”
5. inadequate pain management
“the pain relief offered to Ms [name redacted] (principally simply paracetamol) was completely inadequate”
6. inappropriate nasogastric tube management
“The management of the nasogastric tube that was crucial in attempting to avoid a fatal aspiration was inappropriate”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“I am concerned that this backup plan relied on the availability of a bed at a satellite hospital, which was ultimately not available when it was required.”
This report
“There was a ten day delay in Ms [name redacted] transfer from the Princess Royal Hospital to UCLH.”