“The surgical term ‘nephroureterectomy’ appears to lack sufficient precision to avoid any…”
Dated 9 Jan 2015, from the coroner for West Yorkshire (Eastern). 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
All responses publishedReplies were due by 6 Mar 2015.
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 dated9 Jan 2015
- Deadline6 Mar 2015
- Published on judiciary.uk9 Jan 2015
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Leeds Teaching Hospitals NHS Trust | Response publishedPublished on judiciary.uk in January 2015. |
| Department of Health and Social CareNamed in the report as “Department of Health” | Response publishedPublished on judiciary.uk in January 2015. |
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.
— (1) The surgical term ‘nephroureterectomy’ appears to lack sufficient precision to avoid any possibility of misunderstandings between clinicians as to the extent of the procedure to be performed. One surgeon gave evidence at the Inquest that the term involved the removal of a kidney and the entire ureter. Another surgeon, however, gave evidence that the term was sufficiently broad to allow the removal of only a portion of the ureter. By the time the difference in their understanding of this term of art became clear the deceased had an inoperable tumour located in the remaining portion of the ureter. (2) In this complex case, no firm diagnosis had been established. There was no one person in the clinical team whose role was to monitor progress, liaise with the patient and the various clinicians involved and ensure her significant ongoing problems were heard and heeded. Evidence was taken at the Inquest from an expert witness who described the benefits of a ‘case manager’ role, used in other NHS Trusts in cases characterised by uncertainty and complexity.
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, 2015-0008
- 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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