“In spite of a Trust Root Cause Analysis Report identifying a missed opportunity before…”
Dated 17 Sep 2017, from the coroner for Liverpool and Wirral. 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 12 Nov 2017.
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 dated17 Sep 2017
- Deadline12 Nov 2017
- Published on judiciary.uk25 Sep 2017
- Today22 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Wirral University Teaching Hospital NHS Foundation TrustNamed in the report as “Wirral University Hospital Trust” | Response publishedPublished on judiciary.uk in September 2017. |
The coroner’s concerns
– In spite of a Trust Root Cause Analysis Report identifying a missed opportunity before 13th April 2017 the court has been told at inquest that strategies to avoid a repeated failure were still work in progress. The missed opportunity was not acting upon a reducing trend in a haemoglobin result. This is simply not good enough as this issue should have been fixed during the Root Cause analysis investigation and before the report was approved as soon as the error became evident. During the course of the inquest evidence was heard from several doctors including a surgeon and it was suggested that “when there is a downward trend in haemoglobin of 10% or more the laboratory should always ring through the result as a potential surgical emergency for the urgent review of clinicians” The court brings this to the attention of the Trust and for confirmation as to when a solution to this problem has been implemented
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, 2017-0220
- 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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