26 March 2021

Inquest finds failure to check blood test results to be a critical factor in death of Graham Kitt

Tom Semple represents the family of Graham Kitt who died as the result of a heart attack on 26 August 2018, just over a week after complaining of acute chest pains.

An inquest has found that, crucially, Graham Kitt’s significantly elevated troponin levels, which suggested he had suffered a heart attack, were not acted upon by Hull Royal Infirmary clinicians. The discharging clinician was not aware that the troponin test had been requested. Had the blood tests been checked, marks the coroner, the deceased would have received appropriate treatment and survived.

Noted by the coroner, there was an issue with the software used by Hull University Teaching Hospitals NHS Trust. The concern was attributed to the Trust’s difficulty in finding an IT solution which would alert clinicians to the presence of abnormal test results.

Since the incident, an action plan constructed by the Trust has been implemented. These steps included amending the Trust’s triage pro forma to ensure that all clinicians were aware of what tests had been requested. Further, the coroner will be sending a Prevention of Future Deaths report to NHS England to ensure that similar action is adopted by other Trusts using the same software.