Kinga Cieciorska
13 Jun 2016 · Coroner Zafar Siddique · Black Country
The coroner's concerns
1. missed opportunity to render basic medical care
“Evidence emerged during the inquest that the abnormal ECG trace and tachycardia needed further investigation and she should have been subject to further tests and admitted for further observation to establish the cause of the tachycardia”
2. systemic failings in information transmission
“During the inquest it emerged there was evidence of systemic failings in recording of and transmission of information”
3. failure to consider medication contraindications
“It also emerged during the inquest that details of her medication including the significance of the drug, Diclofenac was not considered”
Responses
No published response was found on judiciary.uk.