the course . of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory to report to you: During the course of the evidence given in this Inquest evidence was received that there had been a failure of communication in communicating the results of haemoglobin level tests. It was further revealed by the evidence that the haemoglobin level was an important factor in considering patient'$ fitness for surgery: The evidence further revealed that had the information concerning the most recent haemoglobin tests carried out o.the deceased passed the surgery may have been delayed or alternative treatment plans put in place. Whilst the evidence did also indicate that there were risks in delaying surgery there nonetheless had been an admitted failure to communicate the results of recent haemoglobin tests to the anaesthetist and surgeon performing the index surgery. Clearly if the results of a haemoglobin test are an essential part of the assessment of fitness for surgery then the ability to communicate the most recent tests indicates a potential failure which could cause or contribute to future deaths_ S:IAGE PERSONALIAGE InquestslWilliams N Inquest Reg28.docxl for aged During duty