“At the inquest I heard helpful evidence from Consultant Neurologist”
Dated 1 Jul 2015, from the coroner for Staffordshire (South). 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 26 Aug 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 dated1 Jul 2015
- Deadline26 Aug 2015
- Published on judiciary.uk1 Jul 2015
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| University Hospitals of North Midlands NHS TrustNamed in the report as “University Hospital North Midlands” | Response publishedPublished on judiciary.uk in July 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
– (1) At the inquest I heard helpful evidence from Consultant Neurologist. She was frank about failures in communication in 2013 and 2014 and advised me of significant changes since Cannock Hospital was transferred to the Wolverhampton Trust. However also indicated in evidence that she is working regularly 7 days a week and the day before the inquest worked 14 hours (and again this was not unusual). These do appear to be excessive hours with an increased potential for fatal errors. I should be grateful if you could look at this. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation have 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 26th August 2015. 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, 2015-0251
- Added to Minute Book
- 8 Oct 2026
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- 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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