“As a patient with Sickle Cell Disease, Urielle was prescribed prophylactic penicillin to…”
Dated 9 Dec 2025, from the coroner for East London. Sent to 4 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
Deadline passedReplies were due by 3 Feb 2026. A reply may have been sent and not yet published.
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.
- Report dated9 Dec 2025
- Deadline3 Feb 2026
- Published on judiciary.uk19 Dec 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| East London Cooperatives Ltd | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Maylands Healthcare Surgery | Response publishedPublished on judiciary.uk in December 2025. |
| Barts Health NHS Trust | Response publishedPublished on judiciary.uk in December 2025. |
| Department of Health and Social CareNamed in the report as “Department for Health and Social Care” | Response publishedPublished on judiciary.uk in December 2025. |
The coroner’s concerns
– 1. As a patient with Sickle Cell Disease, Urielle was prescribed prophylactic penicillin to mitigate the risk of her developing fatal symptoms arising from typical respiratory infections. Urielle’s mother chose not to collect those prescriptions and administer penicillin to Urielle. Urielle’s specialist doctors believed that her GP was monitoring the prescription and dispensation of the penicillin, whilst Urielle’s GP was misled by Urielle’s mother that the hospital were dispensing the medication directly. The breakdown of communication means that Urielle was left unprotected from opportunist infection which caused this avoidable death. 2. In the weeks prior to her death Urielle’s mother presented her daughter to three separate GPs about a respiratory infection. On each of these three attendances the attending clinician was ignorant of Urielle’s Sickle Cell diagnosis. The reasons for these lapses were, firstly Urielle’s mother did not inform the doctor of the fact and, second, that the doctors did not adequately read the clinical records available to them.
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, 2025-0635
- 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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