“That referrals to consultants at Withybush General Hospital are routinely being dealt…”
Dated 27 Jul 2016, from the coroner for Carmarthenshire and Pembrokeshire. 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
Deadline passedReplies were due by 21 Sep 2016. 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 dated27 Jul 2016
- Deadline21 Sep 2016
- Published on judiciary.uk27 Jul 2016
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Hywel Dda University Health Board | 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
That referrals to consultants at Withybush General Hospital are routinely being dealt with by middle grade doctors and, if in the opinion of the middle grade doctor, the matter then needs a referral to a consultant only then is the matter passed to a consultant. All consultant referrals should be seen by consultants in the first instance. Expert evidence received at the inquest described this practice as not being best practice. That liver function tests were requested but the Health Board declined to undertake these for reasons of demand management on the basis tests had been done some three days earlier. Expert evidence received at the inquest was highly critical of this practice. Whilst 72 hour testing is in accordance with guidance contained in guidance from the Association for Clinical Biochemistry and the Royal College of Pathologists both documents are clear that the guidance must be capable of being overridden if clinically appropriate. There was no evidence of any mechanism to override the guidance or, if such guidance existed, that it was known to staff.
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, 2016-0271
- 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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