“Review of administrative systems for contacting and following up patients who DNA…”
Dated 9 Dec 2016, from the coroner for Nottinghamshire. 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 publishedOrganisations 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 dated9 Dec 2016
- Deadline3 Feb 2017
- Published on judiciary.uk12 Feb 2017
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Sherwood Forest Hospitals NHS Foundation TrustNamed in the report as “Sherwood Forest Hospital Trust” | Response publishedPublished on judiciary.uk in February 2017. |
The coroner’s concerns
– 1. Review of administrative systems for contacting and following up patients who DNA appointments – with such correspondence to becopied to their GPs. 2. System for ensuring RAD alerts are received and acted on timeously. 3. Vascular surgeons based at both KMH and NUH should consider having a clear agreed protocol for obtaining custom-made grafts – to include such matters as : a. A clear pathway for contacting and sending scan results to manufacturers. b. Limited no of consultants dealing with these cases. c. Clear timetable between first contact with manufacturer and final sign off – with responsibility of a named consultant to ensure there is no delay. d. Advising and updating patients on these timescales. 4. Adequacy of the trust’s investigation of these events – in particular the morbidity and mortality meeting discussion, which was incomplete, and does not refer to delay by the trust at all. 5. Nature and content of the witness statements provided to the coroner, which again refer only to delay by the manufacturer, which is clearly not the central issue in this case.
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, 2016-0439
- 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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