“Evidence was given about the communication between the neonatal intensive care unit and…”
Dated 27 Sep 2013, from the coroner for Avon. 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 publishedReplies were due by 22 Nov 2013.
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; a reply may have been sent and not yet published.
- Report dated27 Sep 2013
- Deadline22 Nov 2013
- Published on judiciary.uk27 Sep 2013
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Bristol NHS Foundation TrustNamed in the report as “University Hospitals Bristol NHS Foundation Trust” | Response publishedPublished on judiciary.uk in September 2013. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
- Evidence was given about the communication between the neonatal intensive care unit and the cardiac unit. Concerns were raised that the cardiac unit were not suited to caring for premature babies and that a protocol or checklist or better communication between NICU and cardiac unit would be helpful to assist the doctors and indeed the nurses in caring for a premature baby on the cardiac ward. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation have the power to take such action. 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Friday 22"4 November, I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons, nanely i 2nd to the LOCAL SAFEGUARDING BOARD (where the deceased was under 18)]. | am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 27'" September 2013
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, 2013-0246
- 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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