Aarav Chopra
13 Jan 2025 · Coroner Louise Hunt · Birmingham and Solihull
The coroner's concerns
1. lack of prophylactic antibiotics for immunocompromised patients
“The inquest heard evidence that patients like [the deceased] who are immunocompromised require additional prophylactic antibiotics for procedures. This is not covered in the current NICE guidelines. My concern is that there is currently no guidance for the use of prophylactic antibiotics in severely immunocompromised patients.”
2. inadequate trainee competence verification
“The inquest heard evidence that there was confusion around the experience and level of the trainee involved. He was thought to be an ST6 when he was an ST4. My concern is that there is no mechanism to evidence trainees experience and competence when they travel to various different hospital trusts as part of their training.”
3. lack of trainee consent process
“The parents of [the deceased] were unaware that a trainee would be doing the liver biopsy. My concern is that there is currently no way to obtain consent when a trainee will be doing the procedure.”
4. unidentified patient risk factors
“[the deceased] had a complex medical background and several risk factors for any procedure. My concern is that there is currently no mechanism to identify individual patient's risk factors so that all clinicians involved in their care are aware.”
5. inadequate learning from deaths
“The initial M&M meeting after [the deceased]'s death was described as inadequate. My concern is that there was no immediate learning from this tragedy and further consideration is needed to ensure a safe and effective mechanism to properly learn from deaths at the earliest opportunity.”
6. incomplete electronic patient records
“I heard evidence that the lack of electric medical records meant clinicians found it difficult to see all of the patient's medication details. My concern is that critical information can be missed if clinicians do not have access to all the clinical records when planning treatment.”