“Evidence emerged during the inquest that there were failures to record and endorse the…”
Dated 30 May 2017, from the coroner for Black Country. 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 dated30 May 2017
- Deadline25 Jul 2017
- Published on judiciary.uk4 Aug 2017
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| The Royal Wolverhampton NHS TrustNamed in the report as “Royal Wolverhampton NHS Trust” | Response publishedPublished on judiciary.uk in August 2017. |
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. Evidence emerged during the inquest that there were failures to record and endorse the name of the Doctor reviewing the ECG and a failure to take into account previous abnormal ECG results during the handover from the paramedic 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, 2017-0176
- Added to Minute Book
- 8 Oct 2026
- Reuse
- 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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