During the course of the inquest Inoted the full contents of the report provided byL who could not attend to give oral evidence, and it was his view that upon Jane's initial arrival at the hospital she did not present with sufficient clinical signs to justify a blood sample to determine serum sodium levels, and that there was no evidence to suggest that an early blood sample would have led to a much longer survival. This was at variance t0 the oral evidence heard an independent expert in Anaesthesia and Intensive Care Medicine, and I accepted his view thathad an early blood sample been taken prior to her collapse, it would have identified her low sodium levels such that she would have received effective treatment that would on the balance of probabilities have prevented her death: The MATTER OF CONCERN is as follows: The effectiveness of local protocols and the sufficiency of existing hospital guidelines alerting clinicians to the risks of ecstasy toxicity, the symptoms and signs it might present. To consider the appropriateness of a clinical protocol which RT3589 taking from provides structure to the initial decision to intervene Or simply monitor; and guidance on what that monitoring should consist of (and when to be concerned and reassess the initial decision)