“During the course of the evidence given in this Inquest evidence was received that there…”
Dated 13 Mar 2014, from the coroner for Teesside. 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 8 May 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 dated13 Mar 2014
- Deadline8 May 2014
- Published on judiciary.uk13 Mar 2014
- Today23 Oct 2026
Watch this report
We’ll email you when a response is published on judiciary.uk, or when the 56 days to reply end with none published there yet. Free, and you can stop with one click.
Responses from each recipient
| Sent to | Response |
|---|---|
| South Tees Hospitals NHS Foundation TrustNamed in the report as “South Tees NHS Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 8 May 2014. A reply may have been sent and not yet published. |
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.
— During the course of the evidence given in this Inquest evidence was received that there had been a failure of communication in communicating the results of haemoglobin level tests. It was further revealed by the evidence that the haemoglobin level was an important factor in considering a patient’s fitness for surgery. The evidence further revealed that had the information concerning the most recent haemoglobin tests carried out on the deceased passed the surgery may have been delayed or alternative treatment plans put in place. Whilst the evidence did also indicate that there were risks in delaying surgery there nonetheless had been an admitted failure to communicate the results of tecent haemoglobin tests to the anaesthetist and surgeon performing the index surgery. Clearly if the results of a haemoglobin test are an essential part of the assessment of fitness for surgery then the ability to communicate the most recent tests indicates a potential failure which could cause or contribute to future deaths. S:\AGE PERSONALI\AGE. Inquests\Williams N.Inquest.Reg28.docx1 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation had 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 10 May 2014. I, the coroner, may extend the period.
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, 2014-0123
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
Something wrong, such as a date or who it was sent to? Report a mistake
Is this report about someone close to you? You can ask us to remove names from our pages.
Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
Ask about this report
AISummaries and questions, with page references. Pro and above.
Sign in to use