Surrey
Coroner Area
Reports: 189
Earliest: Aug 2013
Latest: 10 Apr 2026
77% response rate (above 63% average).
Rainer Wickens
All Responded
2014-0234
20 May 2014
St George’s Healthcare NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Significant delays in clot treatment and CTPA scans were caused by poor communication during handovers and between medical staff. Additionally, medical notes had gaps and vulnerable patients had unsupervised access to stairs.
Action Taken
(AI summary)
St George's Healthcare NHS Trust apologized for sub-optimal care and delays in a Serious Incident investigation. They have shared the investigation's learning outcomes, now investigate all cases of hospital-acquired thrombosis, and have completed some actions from the SI panel's report, with the rest due by 31 July 2014.
Peter Clive Higson
All Responded
2013-0277
24 Oct 2013
Secretary of State for Health
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Concerns arose regarding the detrimental effect of platelet transfusions following stem cell transplants, questioning if such transfusions might sometimes be contraindicated.
Noted
(AI summary)
The Department of Health refers to a report from NHS Blood and Transplant which indicates that prophylactic platelet transfusion was appropriate in this case, and that the respiratory deterioration likely resulted from other causes, highlighting measures in place to minimise the risk of adverse outcomes from platelet transfusions. NHS Blood and Transplant concludes that TRALI was unlikely in this case based on SHOT imputibility criteria, recent studies and current guidelines suggest that the benefits of platelet transfusion outweigh the risk, and they undertake measures to reduce the risk of TRALI.