“2”
Dated 5 Feb 2014, from the coroner for Surrey. 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
Deadline passedReplies were due by 2 Apr 2014. A reply may have been sent and not yet published.
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.
- Report dated5 Feb 2014
- Deadline2 Apr 2014
- Published on judiciary.uk5 Feb 2014
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Ashford and St Peter's Hospitals NHS Foundation TrustNamed in the report as “St Peter’s and Ashford Hospitals” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 2 Apr 2014. A reply may have been sent and not yet published. |
The coroner’s concerns
1. 2. 3. 4. 5. 6. 7. The length of time taken to initially assess Mr Martin in A&E, given his presenting symptoms The significance of Mr Martin’s symptoms were not appreciated at triage The length of time taken to undertake an ECG and blood tests after initial triage The length of time taken to receive the results of these tests The significance of the rise in troponin was not appreciated or acted upon promptly The length of time taken for Mr Martin to be reviewed by a senior member of staff The length of time taken to provide standard pharmacological treatment for chest pain or myocardial infarction 8. A lack of clarity as to the protocol for the management of chest pain in A&E 9. An overall lack of effective documentation RT3872
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, 2014-0055
- 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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