Vijay Sonagara
PFD Report
Historic (No Identified Response)
Ref: 2014-0364
Coroner's Concerns (AI summary)
Critical medical information was not consolidated, as the patient had multiple unamalgamated records and a temporary file, leading to treating doctors being unaware of potentially relevant history.
View full coroner's concerns
The evidence at the inquest was that Mr Sonagara was being seen by the gastroenterologists at Whipps Cross Hospital at the same time as he was considered for surgery byb However; the gastroenterology treatment was recorded in a different set of hospital records using a different hospilal number (but under the same name, same address, and same NHS number). In addition the evidence showed that there was a temporary file containing further medical records. These sets of medical records were not amalgamated or cross referenced. and his team were unaware of the other medical records and the information contained within them_ As a result they were unaware that Mr Sonagara was being actively investigated at the same hospital: The information within the second and third set of records was potentially relevant to the decision making_although my final conclusion was that it would not have being altered the decision t0 operate in this case. My concerns are therefore as follows: (1) Mr Sonagara had two different sets of medical records under two different hospital numbers that were not amalgamated or cross referenced_ (2) In addition a third temporary file of medical records was not incorporated into the permanent file, (3) Potentially relevant information contained in the second and third set of records was available to Mr Sonagara's treating doctors _
Sent To
- Barts Health NHS Trust
Response Status
Linked responses
0 of 1
56-Day Deadline
3 Oct 2014
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 27 February 2013 commenced an investigation into the death of Vijay Sonagara, age 54. The investigation concluded at the end of the inquest on 6 August 2014. The conclusion of the inquest was misadventure. The medical cause of death was Ia multi-organ fallure; 1b alcoholic cirrhosis of the liver complicated by surgery for inguinal hernia repair (operated 8.2.13).
Circumstances of the Death
Mr Sonagara had alcoholic liver disease and on 8 February 2013 underwent routine surgery for repair of inguinal hernia at Whipps Cross Hospital under the care of On 11 February 2013 Mr Sonagara's condition deteriorated rapidly: He was found to have decompensated alcoholic liver disease requiring intensive care treatment_ He was transferred to St Thomas' Hospital where_he died on 22 February 2013
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you andlor your organisation have the power to take such action.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.