Lisa Gale
11 Nov 2024 · Coroner Simon Fox · Avon
The coroner's concerns
1. delayed diagnosis of acute fatty liver of pregnancy
“Blood was taken for liver function tests (LFTs) on admission before her condition was diagnosed;”
2. grossly elevated liver function test results
“[the deceased]'s LFT's were grossly elevated (normal range in brackets) ALT 612 (10-50), bilirubin 122 (<21), creatinine 168 (45-84);”
3. potentially fatal condition acute fatty liver of pregnancy
“This was due to a potentially fatal condition Acute Fatty Liver of Pregnancy - from which she subsequently died;”
4. inadequate reporting thresholds for pregnant patients
“This was because the Royal College of Pathologists' guidelines for urgent reporting only provides for the same with levels above 750 for ALT, 300 for bilirubin and 354 for creatinine and does not provide for different reporting levels for those taken in pregnant women”
5. pregnancy specific risks not reflected in reporting thresholds
“This is despite pregnancy specific conditions such as AFLP being potentially fatal at much lower levels of abnormal LFTs than those set currently by the Royal College of Pathologists”
6. delayed diagnosis of acute fatty liver of pregnancy
“As a result there was a delay in diagnosing her AFLP and starting appropriate treatment”