Stephanie Marks

PFD Report Historic (No Identified Response) Ref: 2016-0233
Date of Report 20 June 2016
Coroner S Fox QC
Coroner Area Avon
Response Deadline est. 15 August 2016
Hospital Death (Clinical Procedures and medical management) related deaths
Judiciary.uk Report PDF
Coroner's Concerns (AI summary)
There was no evidence of a system to ensure daily GP messages were consistently countersigned and acted upon by general practitioners.
View full coroner's concerns
_ There was no evidence that staff check at 6.3Opm each that all GP messages have been countersigned as receivedlacted on by the GP'$, for that day.
Sent To
  • Clevedon Medical Centre
Response Status
Linked responses 0 of 1
56-Day Deadline 15 Aug 2016
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 11"h August 2015 an investigation commenced into the death of Stephanie Louise MARKS, Aged 18. The investigation concluded at the end of the inquest on zuguste June 2016. The conclusion was that the medical cause of death was Ia Sudden cardiac death in a setting of anorexia nervosa and hypokalaemia and the conclusion as to the death was a narrative that read: Miss Marks died from the consequences of untreated hypokalaemia_ CIRCUMSTANCES @F THE DEATH Miss Marks died from untreated hypokalaemia which had been reported to the practice on 31.7.15_ Systems for passing blood results to GP's at that time were inconsistent. Certain improvements in these have been made since Miss Marks' death.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action_
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.