“2 Information Classification: PUBLIC 6 There is a risk of future deaths from decisions to…”
Dated 6 Apr 2025, from the coroner for Cornwall and the Isles of Scilly. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 1 Jun 2025.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated6 Apr 2025
- Deadline1 Jun 2025
- Published on judiciary.uk11 Apr 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Oxford University Hospitals NHS Foundation Trust | Response publishedPublished on judiciary.uk in April 2025. |
The coroner’s concerns
– 2 Information Classification: PUBLIC 6 There is a risk of future deaths from decisions to proceed with major operations without the surgical team having full knowledge of disease progression, this could include operations that may be unnecessary. The error has not been reported through the OUH Incident Reporting process. The error has not been investigated to establish why it happened and how to prevent a reoccurrence. There is no policy, guidance or standard operating procedure regarding how to process medical reports being received at OUH from other hospitals.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2025-0173
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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