Pin
Get email alerts
Request correction
Investigation and inquest
On 27 February 2013 I 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 1a multi-organ failure; 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-████████ for repair of inguinal hernia at Whipps Cross Hospital under the care of ████████. On 21 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.
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 being considered for surgery by ████████. However, the gastroenterology treatment was recorded in a different set of hospital records using a different hospital number (but ████████ under the same name, 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 altered the decision to 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 not available to Mr Sonagara’s treating doctors.
Information checked against the published report and official responses