“As part of the evidence, it became clear there were conflicting views between clinicians…”
Dated 12 Jun 2024, from the coroner for Oxfordshire. 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.
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Report put online after its 56 daysOrganisations 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.
judiciary.uk put this report online on 17 Jul 2026, after the 56 days for replies had ended (7 Aug 2024). These dates can’t tell us whether a reply was due before it went online. A reply may have been sent and not yet published.
- Report dated12 Jun 2024
- Deadline7 Aug 2024
- Published on judiciary.uk17 Jul 2026
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Oxford University Hospitals NHS Foundation Trust | 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. |
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The coroner’s concerns
– 1. As part of the evidence, it became clear there were conflicting views between clinicians regarding the need for an echocardiogram for vulnerable patients pending periprosthetic surgery and the circumstances when surgery might be appropriately delayed pending such a scan. Evidence was heard that the Anaesthetists of Great Britain and Ireland (AAGBI) guidelines regarding echocardiograms (which apply to hip surgery more generally) were incorrectly applied to the circumstances of Mrs Dandridge’s periprosthetic fracture. 2. Having determined that an echocardiogram was required before surgery could take place, it was unclear which clinicians was responsible for expediting such a scan in circumstances where the evidence indicated that delays in surgery is associated with poorer outcomes for vulnerable patients. 3. The Structured Mortality Review was critical of the decision to require an echocardiogram pending surgery. Such a review is designed to provide learning for the Trust to be applied in future cases. The evidence at the Inquest was that the Review had no input from an anaesthetist who may have articulated the medical justification for such an echocardiogram in this instance. Concerns were raised in evidence that without the relevant subject expertise at such Reviews any future learning from a Structured Mortality Review could be inaccurate or misconceived. You should consider a review of your procedures relating to the arrangements for echocardiograms and to the conduct of structured mortality reviews.
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, 2026-0272
- Added to Minute Book
- 8 Oct 2026
- Reuse
- 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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