Marion Luckraft
29 Sept 2023 · Coroner Graeme Irvine · East London
The coroner's concerns
1. biliary sepsis
“Cumulative delays in the execution of diagnostic processes and treatments of the patient probably increased the risk of Mrs [name redacted] developing biliary sepsis”
2. delayed escalation to high dependency unit
“Following the duodenal perforation suffered by the patient there was a failure to promptly escalate her care to a high dependency unit despite her NEWS score of 8”
3. fragmented treatment across sites
“The fragmentation of the patient's treatment across two sites of the Trust contributed to delays in her treatment”
4. absence of clear treatment pathway for biliary sepsis
“The absence of a clear and workable treatment pathway fro biliary sepsis contributed to delays”
Responses
No published response was found on judiciary.uk.