Beryl Foster

PFD Report Historic (No Identified Response) Ref: 2017-0095
Date of Report 29 March 2017
Coroner David Horsley
Coroner Area Portsmouth and South East Hampshire
Response Deadline est. 24 May 2017
Hospital Death (Clinical Procedures and medical management) related deaths
Judiciary.uk Report PDF
No published response · Over 2 years old
Sent To
Response Status
Responses 0 of 1
56-Day Deadline 24 May 2017
Over 2 years old — no identified published response
About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Coroner's Concerns
Mrs Foster's discharge summary was handed to her on 8 December 2015 and was subsequently posted to her GP practice. This meant that when she became unwell the following and contacted practice; it was unaware of the endoscopy the previous was told that endoscopy discharge summaries are posted to GP practices by QAH, rather than emailed like all other discharge summaries. am concerned this practice raises a risk that future deaths will occur in such circumstances and would ask the NHS Trust to consider emailing all discharge summaries to GP practices in the future.
Action Should Be Taken
In my opinion action should be taken t0 prevent future deaths and believe your organisation has the power to take such action day the day:
Report Sections
Investigation and Inquest
On 7 June 2016 commenced an investigation into the death of Beryl Yvonne Foster, aged 76. The investigation concluded at the end of the inquest on 14 March 2017. The conclusion of the inquest was a Narrative Conclusion (which is attached hereto): The medical cause of Mrs Foster's death was: 1a): Respiratory Failure 1(b) . Pneumonia 1(c) . Oesophageal Perforation Ischaemic Heart Disease
Circumstances of the Death
Mrs Foster underwent an endoscopic ultrasound examination at Queen Alexandra Hospital on 8 December 2015. She became unwell after discharge from the hospital and was re-=
-admitted on 11 December 2015 and subsequently died there on 2 January 2016.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.