Hariharan Harichandra
5 Jan 2021 · Coroner Edwin Buckett · Inner North London
The coroner's concerns
1. CT scan reporting error
“There was an error in the reporting of the CT scan by the original clinician”
2. wheelchair safety oversight
“The staff who moved Mr [name redacted] did not examine his wheelchair for a belt which would have kept him secure”
3. falls assessment failure
“The Falls Assessment Tool was not properly completed or reviewed by staff”
4. lack of equipment training
“Hospital staff have no training in how to assess and deal with private equipment brought from outside such as an electric wheelchair and the safety features of such devices”
5. Naso-Gastric tube adverse reaction
“Mr [name redacted] suffered a severe adverse reaction to the use of a Naso-Gastric tube on the 19th December, 2019 which was closely associated with terminal events”