Jyoti Rao

I am Chris Morris, Area Coroner for Greater Manchester (South).

On 19 th June 2024, Alison Mutch, Senior Coroner for Greater Manchester (South), opened an inquest into the death of Jyoti Rao, who died on 20 th February 2024 at Tameside General Hospital, Ashton- under-Lyne, aged 56 years. The investigation concluded with an inquest which I heard on 16 th September 2024. The inquest determined that Miss Rao died as a consequence of:- 1) a) Hypoxic-ischaemic brain injury; b) Sepsis on background of end-stage renal failure with failure of transplanted kidney. II Traumatic nasogastric tube insertion The conclusion of the inquest was a Narrative Conclusion, to the effect that Miss Rao died as a  consequence of complications arising from renal transplantation.

Miss Rao died on the 20 th February 2024 at Tameside General Hospital, Ashton-under-Lyne as a  consequence of Hypoxic-ischaemic brain injury due to sepsis on the background of end-stage renal failure with failure of a transplanted kidney. Miss Rao’s death was contributed to by traumatic  nasogastric tube insertion.

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. – Whilst the court heard evidence as to the advantages of the ‘Consultant of the Week’ model in  terms of team working, it is a matter of concern that complex transplant patients such as Miss Rao  are not allocated a named consultant, who not only (in conjunction with others) can seek to ensure continuity of care is provided, but also who can take a longer-term view of the patient’s post- operative course and trajectory when complications arise.

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.