“The inquest heard that waiting times to be seen in Majors A&E at Newham University…”
Dated 27 May 2025, from the coroner for East 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 22 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 dated27 May 2025
- Deadline22 Jul 2025
- Published on judiciary.uk29 May 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Barts Health NHS TrustNamed in the report as “Barts Health NHS Foundation Trust” | Response publishedPublished on judiciary.uk in May 2025. |
The coroner’s concerns
1. The inquest heard that waiting times to be seen in Majors A&E at Newham University Hospital could sometimes be between 9 to 14 hours. Many patients are unable to tolerate such long waits and leave the department before being seen. 2. There was no timely triage of Majors patients by the medical team, to ensure that those with the greatest potential of clinical decline are picked up quickly and appropriate investigations commenced at an early stage. Without such frontloading of care, patients like Abdirahman who might compensate right up to the point of collapse, might be missed again. 3. When the doctor called Abdirahman the following afternoon, she did not have all of the relevant clinical information to hand. She was not aware of the compensated metabolic acidosis. It is unlikely that she advised Abdirahman of the importance of returning to the hospital. It is foreseeable that patients may be reticent to return to A&E, because of the lengthy waits, so doctors making the call to patients who have left, should be fully informed about the clinical condition and risks. The risk of not returning should be made very clear. 4. Abdirahman was 17 years old. He declined to return to A&E. There was no direct discussion with a responsible parent about the need to return to A&E. 5. When Abdirahman stated that he would be seeing his GP later that afternoon, he asked for the relevant results to be sent to the GP. Neither the results, nor the discharge summary were sent to the GP in time for the appointment. The inquest heard that the A&E doctor did not know how to share such information with the GP. 2
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, 2025-0245
- 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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