Clara Moniatis
Report response
Published responseThis status records whether a response is published for this PFD report, regardless of which body sends it. It does not establish that every recipient answered or that the reply was complete or on time. Private replies may not be published.
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PFD reports and published responses
- PFD reports
- Separate PFD reports in InquestIQ, each counted once. A report can concern several people or be addressed to several organisations. This is not a count of deaths, inquests or PDF files.
- With response
- Reports with at least one linked published response. The reply can come from any body, including a parent body or someone answering on another organisation's behalf. Several letters still count as one report with a response.
- No published response
- Reports for which no published response is linked in InquestIQ. A private reply, an unpublished reply or a reply not yet identified may exist.
- Response coverage
- Reports with a published response divided by total reports, multiplied by 100. For example, 3 out of 4 is 75%. Percentages are rounded. Coverage does not measure whether every recipient answered, replied on time or took adequate action.
Figures reflect records currently held in InquestIQ and may change as sources are added or corrected. Read the full counting guide.
Report addressed to
Report Content
Report text
Date of report: 3 November 2020 Ref: 2020-0221 Deceased name: Clara Moniatis Coroner name: Caroline Beasley-Murray Coroner Area: Essex Category: Hospital death (Clinical procedures and medical management) related deaths This report is being sent to: Barts and Whipps Trust
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Barts and Whipps trust
Coroner
I am Caroline Beasley-Murray, senior coroner, for the coroner area of Essex
Legal Powers
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I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
Investigation and Inquest
On 15 May 2019 I commenced an investigation into the death of Clara Iris Moniatis.. The investigation concluded at the end of the inquest on 7 October 2020. The conclusion of the inquest was:- Clara Iris Moniatis had been unwell for some days and on the morning of 5 May 2019 she was taken to the Emergency Department of Whipps Cross Hospital. Despite medical treatment, she died there at 18.56pm that evening. She died of Natural Causes.
Circumstances of Death
The cause of death was 1a) dilated cardiomyopathy. This condition had been previously undiagnosed Please see above
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. –
- The matter of waiting times from chest x-ray to the review of the imaging
- The matter of the need for a system whereby a PEWS alert leads to a prompt
clinical review
Action Required
In my opinion action should be taken to prevent future deaths and I believe you and your 1 organisation have the power to take such action.
Your Response
You are under a duty to respond to this report within 56 days of the date of this report, namely by 18th December 2020. 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.
Copies and Publication
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I have sent a copy of my report to the Chief Coroner and to the following Interested Persons- solicitors for the family I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 3 November 2020 Caroline Beasley-Murray 2
Details
- Report Date
- 17 December 2020
- Coroner
- Caroline Beasley-Murray
- Coroner Area
- Essex
- Reference
- 2020-0221
Related reports
Percentages are automated text-similarity scores, not response coverage or proof that the reports concern the same facts.
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