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A coroner has demanded a hospital trust take action to prevent future deaths after a cancer patient's was "hastened" because she was not under sufficient observation on the ward.
Johanna Moreland died at Medway Maritime Hospital in Gillingham four days after going in for a biopsy as part of treatment for advanced liver cancer.
But coroner Sonia Hayes found the 59-year-old's death on March 8 had been "hastened by a short time" following the procedure.
A report issued by Ms Hayes has now called on Medway NHS Foundation Trust bosses to set out what action they plan to take to avoid an incident happening again.
She said: "During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken."
The inquest, which concluded at Archbishop's Palace in Maidstone, heard Ms Moreland died from an abdominal bleed caused by liver cancer following the biopsy procedure.
The coroner's report to the hospital trust said test results which are usually available within 48 hours only came back after six days.
Ms Hayes said evidence at the inquest heard "in the absence of the test results" a decision to carry out a biopsy was taken which had also led to "a delay in antiviral treatment" starting.
After the biopsy took place, Ms Hayes said Ms Moreland returned to the ward but the trust's policy on "the required levels of observation" had not been followed.
The inquest heard this was due to "miscommunication between trust staff" and the required amounts of observations not being recorded in medical records.
In a notice served by Ms Hayes to the chief executive of Medway NHS Trust, Dr George Findlay, she says the trust must respond by September 5 to demands for actions which will prevent future deaths.
She said: "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.
"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."
Dr Findlay said: “I’d like to express my most sincere condolences to the family of Ms Moreland for their loss, we take concerns raised by the coroner very seriously and we are looking into the issues that have been raised during the inquest.
"We will be responding to the coroner within the 56 day deadline and will ensure that we take any necessary actions to address the issues that have been identified.”
For more information on how we can report on inquests, click here.
