“It was established during the inquest that here was no pathway or guideline in place for…”
Dated 16 Nov 2015, from the coroner for Mid Kent and Medway. 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 11 Jan 2016.
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 dated16 Nov 2015
- Deadline11 Jan 2016
- Published on judiciary.uk16 Nov 2015
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Maidstone and Tunbridge Wells NHS Trust | Response publishedPublished on judiciary.uk in November 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) It was established during the inquest that here was no pathway or guideline in place for post ERCP patients who develop complications (2)Out of hours radiography can only be referred on a consultant to consultant basis. There is no surgical consultant on call from Maidstone during the working week although there is a surgical consultant at Tunbridge Wells 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 1 4" January 2016. |, 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, 2015-0436
- 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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