“The inquest heard evidence from , stroke consultant, that, at the time of these events…”
Dated 16 Feb 2026, from the coroner for Cornwall and the Isles of Scilly. 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 13 Apr 2026.
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 dated16 Feb 2026
- Deadline13 Apr 2026
- Published on judiciary.uk23 Feb 2026
- Today23 Oct 2026
Watch this report
We’ll email you when a response is published on judiciary.uk, or when the 56 days to reply end with none published there yet. Free, and you can stop with one click.
Responses from each recipient
| Sent to | Response |
|---|---|
| NHS Cornwall and the Isles of Scilly Integrated Care BoardNamed in the report as “Cornwall & Isles of Scilly Integrated Care Board” | Response publishedPublished on judiciary.uk in February 2026. |
| Royal Cornwall Hospitals NHS Trust | Response publishedPublished on judiciary.uk in February 2026. |
The coroner’s concerns
1) The inquest heard evidence from , stroke consultant, that, at the time of these events, only 35% of patients were admitted to a stroke unit from an ED within 4.5 hours, while only 55% of patients were spending over 90% of their time on a stroke unit. Further, that there were approximately 80 admissions of stroke patients/month or about 900/year. The obvious concern was that there was a capacity issue in Cornwall concerning the timely admission and treatment of stroke patients.
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, 2026-0095
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
Something wrong, such as a date or who it was sent to? Report a mistake
Is this report about someone close to you? You can ask us to remove names from our pages.
Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
Ask about this report
AISummaries and questions, with page references. Pro and above.
Sign in to use