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No radiological examination was ordered.
Margaret's condition was seen to deteriorate and an early
warning score was noted at 4am on 19 February. This was not
communicated to the clinicians. Further abnormal blood tests
later that day indicated a likely inflammation or infection
of the pancreas and an order for an urgent CT scan and intravenous
antibiotics was made on the morning of 21 February. However,
this order was subsequently cancelled although no reason was
documented.
Margaret was discharged from hospital later that day without
further tests, but sadly she died between 11pm that night
and 6 am the following morning.
We represented Margaret's family at the Coroner's Inquest
in March 2006. It became clear in evidence that system failures
at the hospital had contributed to Margaret's death and the
verdict of the Coroner was death by "natural causes following
inappropriate discharge from hospital, due in part to failings
in the system of communication".
Results of the case
It is not often that a Coroner will reach a verdict so strongly
supportive of a presumption of negligence and, as a result,
we hope to achieve a good settlement for Margaret's family
in their civil claim against the hospital.
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