Skip to content
recurance

Teresa Auriemma

14 Nov 2024 · Coroner David Reid · Worcestershire

The coroner's concerns

  1. 1. failure to monitor electrolytes before prescribing IV potassium

    “None of the doctors caring for Mrs. [name redacted] from 11.3.24 onwards appear to have heeded the guidance of policy WAHT-PHA-020 for the treatment of hypokalaemia, and in particular that daily monitoring of urea and electrolytes ( U&E ) was required until the patient's potassium levels had returned to normal levels. Mrs. [name redacted] had been prescribed an oral potassium supplement from 11.3.24. A junior doctor assisting the consultant on the ward round on 15.3.24, when asked what Mrs. [name redacted] potas”

Responses

  • Built with
  • NVIDIA Nemotron Nano, Super and Ultra
  • Nebius Token Factory inference
  • Qwen3 Embedding 8B on Token Factory
  • Tavily follow-up web search
  • Postgres and pgvector search
  • Next.js site

Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error