“Birmingham Children’s Hospital NHS Foundation Trust has a policy in place and/or…”
Dated 20 Feb 2015, from the coroner for West Yorkshire (Eastern). Sent to 5 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
Deadline passedReplies were due by 17 Apr 2015. 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 dated20 Feb 2015
- Deadline17 Apr 2015
- Published on judiciary.uk20 Feb 2015
- 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 |
|---|---|
| REDACTED | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| REDACTED | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Sheffield Children's NHS Foundation TrustNamed in the report as “Sheffield Children’s NHS Foundation Trust” | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Leeds Teaching Hospitals NHS Trust | Response publishedPublished on judiciary.uk in February 2015. |
| British Society of Paediatric Gastroenterology | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
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) Birmingham Children’s Hospital NHS Foundation Trust has a policy in place and/or guidelines dealing with paediatric endoscopy procedures for the bandi of an oesophageal varixloesophageal varices (“the procedure’). Neither Sheffield Children’s NHS Foundation Trust nor Leeds Teaching Hospitals NHS Trust has such a policy and/or guidelines. Both of the latter Trusts have undertaken the said procedure for many years. (2) There is no standardisation of practices (either locally or nationally) adopted by Consultants when undertaking the said procedure, by reason predominantly of there being no national policy and/or guidelines in relation thereto. Such a national policy and/or guidelines should address the following:- (a) Precise definitions of the grades of oesophageal varices; () Which grades of varices should be subject to banding and which should not; (©) Those patients who are to be deemed suitable for placing on a banding programme and those who are not; (d) Once a patient is placed on a banding programme, the assessment process. to be adopted prior to the said patient undergoing each procedure; (e) Post endoscopy care, for example, the administration of sucralfate, frequency of basic observations; (f) The steps to be taken to properly assess for and manage variceal bleeding, for example, the immediate use of antibiotics; (g) The circumstances in which a Consultant is deemed to be competent to undertake the procedure alone or with supervision. ‘ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the Power to take such action.
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, 2015-0070
- 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