Peter Carroll

1. The biopsy taken on 6th October 2016 was not recorded on the

deceased’s discharge notes. Therefore, the treating consultant and administrative staff were unaware of the need to chase results or indeed the seriousness of the results.

1. The sample was wrongly labelled and as a result not reported to the

multidisciplinary team warranting earlier action. Although certain measures have been implemented to try to prevent recurrence, I am not satisfied that this is sufficient. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: I am concerned that there is no leading physician signing off these reports in addition to processing by input on it systems thus reducing the effectiveness of the reporting. I am concerned that a 6 month delay in reporting, on the evidence, meant that a curable treatment was not an option however if reported in a timely manner, would most likely have resulted in a favourable outcome. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Tuesday 7th May 2019. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to Interested Persons. I have also sent it to organisations who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response.