“During the course of the inquest I heard that as a result of the Patient Safety Incident…”

The coroner’s concerns

– 1. During the course of the inquest I heard that as a result of the Patient Safety Incident Investigation (“PSII”) into Stephanie’s death which concluded in May 2025 a safety action was recommended and accepted by the Trust which was aimed at promoting a clear Multidisciplinary Team approach and care pathway for patients with acute pancreatitis. The target date for implementation of this action was the 30th August 2025. 5 2. The agreed safety action was, in summary, that a meeting was to be conducted between all UHB hospital sites to discuss and confirm a pathway for patients with complex pancreatitis and to include agreement on (i) the threshold for referring patients between sites (e.g. from Good Hope Hospital to Heartlands Hospital or Queen Elizabeth Hospital which is the regional hepatobiliary specialist centre) including timescales (ii) confirmation on how referrals, treatment pathways and outcomes (including MDT outcomes) are documented on each site and processes for ensuring these are visible between sites and (iii) the processes for shared care between hospital sites and services. 3. However, I heard evidence from one of the Trust’s clinical delivery group medical directors that, as at the date of the inquest, whilst meetings had taken place between the specialisms at the different hospital sites regarding the proposed care pathway/MDT arrangements and a draft document setting these out had been discussed, this is still to be finalised and shared with all relevant staff. 4. In this case, I was satisfied that the absence of an effective MDT approach to the management of Stephanie’s condition had a more than minimal contribution to her death. I am therefore concerned that there remains a risk of future deaths until such time as there is an agreed, documented care pathway for patients with complex acute pancreatitis that is accessible to and understood by clinicians across the different UHB hospital sites.

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, 2026-0224

Added to Minute Book

8 Oct 2026

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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