Fadzai CHITAKUNYE · Prevention of Future Deaths report

On 01 March 2019 I commenced an investigation into the death of Fadzai CHITAKUNYE aged 45. The investigation concluded at the end of the inquest on 29 March 2022. The conclusion of the inquest was Natural Causes due to

1a) Haemorrhage into high grade astroglial brain tumour

2) Progression of hepatitis B infection following chemotherapy

Fadzai Chitakunye was diagnosed with a brain tumour in 2010. Her compliance with the advised treatment was not always consistent. She had been diagnosed with hepatitis B in 2004 in Nottingham but this information had not been passed onto her general practitioner until 2010. She was not referred to a hepatologist and the oncologist treating her was unaware of her hepatitis B infection. If she had been, it is likely that Mrs Chitakunye would have been given anti-virals whilst having the chemotherapy treatment which might have improved her liver disease. Mrs Chitakunye died from a haemorrhage into her brain tumour on the 26 February 2019 at Leicester Royal Infirmary. It is not entirely certain whether the haemorrhage was exacerbated by deranged coagulopathy due to her liver disease.

In this case the transfer of the notes from the deceased’s Nottingham general practitioner to the Leicestershire general practitioner took 11 months as reported to me by the GP. She also reports that notes still take about 16 weeks to be transferred between GP’s. Important information about the patient’s medical history may be missed particularly if the patient is not able to communicate effectively with the new GP.