“2”
Dated 26 Oct 2016, from the coroner for Birmingham and Solihull. 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 21 Dec 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 dated26 Oct 2016
- Deadline21 Dec 2016
- Published on judiciary.uk26 Oct 2016
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| The Dudley Group NHS Foundation TrustNamed in the report as “Dudley Group of Hospitals NHS Foundation Trust” | Response publishedPublished on judiciary.uk in October 2016. |
| University Hospitals Birmingham NHS Foundation TrustNamed in the report as “University Hospitals Birmingham NHS Trust” | Response publishedPublished on judiciary.uk in October 2016. |
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. 2. 6 There was poor communication between both hospitals in relation to Alfie’s condition and care. Details of his neurosurgical review on 16/05/16 were not made available to Russell’s Hall Hospital. His clinical condition was not relayed to QE hospital on 27/05/16 or morning of 06/06/16. These were vital missed opportunities to transfer him back to QE for treatment. Both Trusts need to look at their communication systems and identify areas for improvement and to clarify if the NORSE system is effective. I heard evidence to suggest that all the NORSE system entries cannot always be seen. Education. It is important the clinicians in outlying hospitals understand how neurological referrals should be made and when. Better guidance and education is needed for outlying hospitals.
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, 2016-0382
- 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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