“The Barts Health Trust chose not to investigate this case as part of NHS England’s…”
Dated 10 Mar 2026, from the coroner for East London. 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
Deadline passedReplies were due by 5 May 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 dated10 Mar 2026
- Deadline5 May 2026
- Published on judiciary.uk12 Mar 2026
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Barts Health NHS Trust | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 5 May 2026. A reply may have been sent and not yet published. |
| Department of Health and Social CareNamed in the report as “Department for Health and Social Care” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 5 May 2026. A reply may have been sent and not yet published. |
The coroner’s concerns
– 1. The Barts Health Trust chose not to investigate this case as part of NHS England’s Patient Safety Framework. Mr Ioannou’s death ought to have been subject to such an investigation. Firstly, despite an autopsy, the aetiology and precise timing of Mr Ioannou’s fatal infection was not fully understood. In a functioning clinical governance setting, both the possibility of the trust having missed a pre-existing infection at the time of the treatment on 23rd June 2025 or the prospect that the treatment itself caused the infection should have been explored. Secondly, in the context of the treatment of a patient with a profound learning disability where communication failures may have contributed to poor care, a valuable learning opportunity was missed.
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, 2026-0137
- 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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