“following the inquest into Ms Morgan-Gray’s death were as follows: 1”
Dated 7 May 2025, from the coroner for Inner North London. 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 2 Jul 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 dated7 May 2025
- Deadline2 Jul 2025
- Published on judiciary.uk20 May 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Medicines and Healthcare products Regulatory AgencyNamed in the report as “MHRA” | Response publishedPublished on judiciary.uk in May 2025. |
The coroner’s concerns
following the inquest into Ms Morgan-Gray’s death were as follows: 1. A concern regarding the interpretation of blood gas machine readings. Specifically, when blood glucose levels are unrecordably low, the machines report this as ‘- - -↓’. This display can be misinterpreted as indicating the sample is unanalysable, rather than accurately reflecting an extremely low glucose level. This misinterpretation could lead to delayed or inappropriate clinical responses, potentially resulting in future deaths. It was unclear why the results are not recorded as ‘Low’ or similar. As the regulator of medical devices, I made the decision to write this report to you, rather than an individual manufacturer, as I believe you have the power to direct all manufacturers of such devices to ensure they provide clear and easily interpretable results. 6 ACTION COULD BE TAKEN In my opinion action could be taken to prevent future deaths and I believe that the addressee has the power to take such action.
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, 2025-0217
- Added to Minute Book
- 8 Oct 2026
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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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