Lindy Aston
8 Dec 2023 · Coroner Isobel Thistlethwaite · Leicester City and South Leicestershire
The coroner's concerns
1. delayed life-saving surgery for splenic rupture
“The inquest heard that Mrs [name redacted] should have been categorised as a high-risk”
2. single surgeon decision making without checks
“The inquest heard evidence to confirm that the decision making as to whether a patient is operated on or not is entirely the remit of the surgical team at Kettering General Hospitals NHS Trust”
3. lack of incident reporting
“The inquest was advised that a DATIX incident report was not raised in relation to Mrs [name redacted] care or death”
4. inadequate post-event investigation
“The Trust's exploration of the care provided to Mrs [name redacted] failed to identify the fact that surgery should have been undertaken within an hour”