“(brief summary of matters of concern) Although I accept that a system of audits is now…”
Dated 20 Apr 2026, from the coroner for West Sussex, Brighton and Hove. Sent to 1 organisation or person.
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 publishedOrganisations 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 dated20 Apr 2026
- Deadline15 Jun 2026
- Published on judiciary.uk17 Jun 2026
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| University Hospitals Sussex NHS Foundation Trust | Response publishedPublished on judiciary.uk in June 2026. |
The coroner’s concerns
(brief summary of matters of concern) Although I accept that a system of audits is now under way, these are evidently retrospective and the changes made do not appear to fully resolve the observed weaknesses and risk of differences apparent in the inquest within the GP-Consultant surgeon-Careflow booking chain whereby the urgency expressed by the GP does not successfully translate into an urgent booking, because there remains the risk of manual coding error and/or that there is no express reason given or reported back to the GP as to why their patient is or will be afforded the proposed urgency. Again, although there is current and considerable planned progress on integration of IT systems, this work is not yet complete and referrals remain reliant on 3 separate systems which are not yet fully joined up. Incidental findings from tests conducted in the ED are not always reported Regulation 28 – After Inquest Template Updated 15/07/2025 TG to the GP where these may not relate to the presenting complaint. ED policy appears to remain inconsistent. This is especially important as it means a Patient with a significant condition, for which they are under their GP, may have a change in that condition identified at the ED which is not then always reported back or highlighted urgently to the GP.
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, 2026-0242
- 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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