“During the course of the inquest, evidence was given to me that a level of complexity due…”
Dated 26 May 2026, from the coroner for Devon, Plymouth and Torbay. 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
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 13 Aug 2026, after the 56 days for replies had ended (21 Jul 2026). 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 dated26 May 2026
- Deadline21 Jul 2026
- Published on judiciary.uk13 Aug 2026
- Today24 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| NHS Devon Integrated Care BoardNamed in the report as “NHS Devon” | 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. |
| NHS Cornwall | 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. |
The coroner’s concerns
During the course of the inquest, evidence was given to me that a level of complexity due to the Deceased’s medical history, his injuries and an apparent artifact in the CT-Scan caused by metalwork in the Deceased’s spine from previous fusions required the expertise of a consultant radiologist. I was informed that there was (and is still) no out of hours consultant radiologist cover for hospitals in Exeter, Plymouth and Torbay. I am concerned that there will be from time to time a need for scans and x-rays to be considered and interpreted at consultant radiologist level to facilitate urgent treatment and there is at present a gap in such cover which puts patients at risk. 10. COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: 1.The Deceased’s Family 2.Torbay and South Devon Healthcare NHS Foundation Trust I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. SIGNATURE Stephen Covell - Assistant Coroner 4
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, 2026-0301
- 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
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