“5 1”
Dated 3 Jun 2025, from the coroner for Birmingham and Solihull. Sent to 2 organisations or people.
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 29 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 dated3 Jun 2025
- Deadline29 Jul 2025
- Published on judiciary.uk11 Jun 2025
- Today21 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| University Hospitals Birmingham NHS Foundation Trust | Response publishedPublished on judiciary.uk in June 2025. |
| Department of Health and Social Care | Response publishedPublished on judiciary.uk in June 2025. |
The coroner’s concerns
– 5 1. The investigation by the hospital trust identified that at the time of Mr Villers’ presentation to hospital on 18/05/24 there were insufficient radiologists to report the large number of CT scans undertaken over the weekend period. This was one of the root causes of the very subtle abnormality indicating aortic dissection being missed when the scan was reported. The inquest heard evidence that whilst the situation had improved the number of radiologists was still not in accordance with Royal College of radiology guidelines thus creating a risk of future deaths and in my view, action should be taken.
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, 2025-0269
- Added to Minute Book
- 8 Oct 2026
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- 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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