Caroline Lee
PFD Report
Historic (No Identified Response)
Ref: 2013-0228
Coroner's Concerns (AI summary)
Medical staff failed to recognise the significance of abnormal potassium results, compounded by the laboratory's failure to inform ward staff promptly, hindering timely intervention.
View full coroner's concerns
_ failure of the medical staff to recognise the significance of the potassium results (2) failure of the laboratory to inform the Ward staff of the abnormal potassium results
Sent To
- University Hospital Coventry and Warwickshire
Response Status
Linked responses
0 of 1
56-Day Deadline
6 Oct 2013
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 24 June 2013 commenced an investigation into the death of Caroline LEE 49 years old. investigation concluded at the end of the inquest on 11 September 2013. The conclusion of the inquest was a Narrative Verdict (Copy attached)
Circumstances of the Death
See Narrative Verdict
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you as Chief Executive of the Trust have the power to take such action:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.