“University Hospitals of Leicester NHS Trust (“the Trust”) prepared an Investigation…”
Dated 18 Sep 2014, from the coroner for Leicester City and South Leicestershire. 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 13 Nov 2014.
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 dated18 Sep 2014
- Deadline13 Nov 2014
- Published on judiciary.uk18 Sep 2014
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| University Hospitals of Leicester NHS Trust | Response publishedPublished on judiciary.uk in September 2014. |
The coroner’s concerns
– University Hospitals of Leicester NHS Trust (“the Trust”) prepared an Investigation report concerning this death, and this was signed off on 15th January 2014. A copy was duly provided to the Coroner’s office in accordance with the local approved information sharing agreement. On the day of the inquest itself, nearly 9 months later, without any amendments or further communications from the Trust, Evidence was heard that (1) the Trust acknowledged that the report was factually incorrect 1 (2) That the only 2 “Root causes” identified in the report were incorrect (3) the Clinical Lead (who signed off the Investigation Report) said it was “flawed” and “not helpful” I am therefore concerned that the Trust is providing inaccurate and misleading investigation reports, and Action Plans based on the erroneous findings that are not only of no assistance, but in fact divert attention away from the actual difficulties in service provision that should be identified. This not only fails to achieve the intention of the investigation, but also has the potential to miss opportunities to prevent future deaths. Furthermore, there was a failure to communicate the Trust knowledge of the Investigation Reports shortcomings until the day of the Inquest itself, and it was clear no attempts had been made to revisit the report to correct the recognized errors. I request to be advised of any actions that have been taken to improve and oversee the preparation and conclusions of Investigation Reports, and that consideration be given to introduce a system to re-open any reports found to be inadequate or erroneous.
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, 2014-0408
- 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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