UK Inquiry Tracker

Janet Hall

PFD Report Historic (No Identified Response) Ref: 2018-0082

Date of Report 14 March 2018

Coroner Chris Morris

Coroner Area Manchester (South)

Response Deadline est. 11 August 2018

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

The Emergency Department system, relying on manual transcription of blood results by junior doctors, led to incorrect discharge letters and prevented GPs from effective trend analysis.

View full coroner's concerns

_ Following Mrs Hall's attendance at the Royal Oldham Emergency Department, a letter was written to her GP which included the text 'Bloods and ECG all normal' . The evidence before the court was that contrary to this statement, Mrs Hall's full blood count was, in fact; abnormal, with a slightly low haemoglobin at 96 grams litre. Consultant in Emergency Medicine, explained in his evidence that in contrast to other systems Which operate across the Trust whereby complete sets of results are automatically incorporated into discharge letters, the Emergency Department system is currently predicated on junior doctors accurately transcribing significant individual results_ In addition to increasing the chances for errors of the sort that occurred in this case, it is 3 matter of concern that the absence of a complete set of blood results in discharge letters reduces the potential for GPs to compare results with others on their own systems, reducing the opportunity for trend analysis.

Sent To

Pennine Acute Hospitals NHS Trust

Response Status

Linked responses 0 of 1

56-Day Deadline 11 Aug 2018

About PFD responses

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

Source: Courts and Tribunals Judiciary

Report Sections

Investigation and Inquest

On 10"h October 2017,an inquest was opened into the death of Janet Hall, who died aged 67 years at Tameside General Hospital, Ashton under Lyne on 18'h September 2017 The investigation concluded at the end of the inquest which heard on 21s February and 12th March 2018. conclusion of the inquest was that Mrs Hall died as a consequence of acute heart failure. Although Mrs Hall had underlying ischaemic heart disease, her heart failure was precipitated by very advanced B Cell lymphoma which had not been diagnosed at the time of her death: The conclusion of the inquest was natural causes:

Circumstances of the Death

Mrs Hall first presented to her GP with symptoms of left leg and back pain on 22nd May 2017 The was not relieved by anti-inflammatories, ad continued to progress with increasing analgesia requirements over the course of the summer. On 19'h July 2017, Mrs Hall attended the Emergency Department of The Royal Oldham hospital, complaining of palpitations and a raised heart rate: She was discharged following examination and investigations with a request that her GP arrange cardiology follow up On 9th August 2017, Mrs Hall attended her GP with leg swelling: Her GP referred her to the Vascular Studies centre at Tameside General Hospital where, the following day a scan confirmed the presence ofan extensive Deep Venous Thrombosis. Mrs Hall was admitted to hospital for further investigations, pain relief and anti-coagulant therapy: There then followed a series of admissions attendances to Tameside General Hospital, culminating in Mrs Hall's sad death on 8th September 2017 The medical cause of Mrs Hall's death was:
1)a) Acute left ventricular failure; b) B Cell Iymphoma on background of ischaemic heart disease_ The pain and

Action Should Be Taken

In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action.