Sultana Choudhury
7 Sept 2023 · Coroner Graeme Irvine · East London
The coroner's concerns
1. ongoing renal haemorrhage
“The trust's failure to diagnose an obvious ongoing renal haemorrhage in a patient with; a recent history of renal biopsy, worsening clinical observations in keeping with hypovolaemia and a plummeting haemoglobin count.”
2. administering VTE prophylaxis to patient with patent bleed
“The clinical decision to administer VTE prophylaxis in the form of low molecular weight heparin on admission to a patient with a patent bleed, evidenced by haematuria.”
3. inadequate monitoring of Mrs Choudhury
“The failure to adequately monitor Mrs [name redacted] during her 3-day admission that allowed her to deteriorate into a preventable peri-arrest state.”
Responses
2023-0321-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
Stated action · June 2023
“the Trust produced a Comprehensive Investigation Report in June 2023 to identify the cause of Mrs [name redacted] death and developed a robust action plan to share learning across the Trust.”