“provide the basic resources”
Dated 8 Dec 2017, from the coroner for Brighton and Hove. 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
Report put online after its 56 daysOrganisations 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.
judiciary.uk put this report online on 11 Feb 2018, after the 56 days for replies had ended (2 Feb 2018). These dates can’t tell us whether a reply was due before it went online. A reply may have been sent and not yet published.
- Report dated8 Dec 2017
- Deadline2 Feb 2018
- Published on judiciary.uk11 Feb 2018
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Brighton and Sussex University Hospitals NHS Trust | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 11 Feb 2018, after the 56 days for replies had ended (2 Feb 2018). These dates can’t tell us whether a reply was due before it went online. |
| St George's University Hospitals NHS Foundation TrustNamed in the report as “St George’s University Hospitals NHS Trust” | Response publishedPublished on judiciary.uk in February 2018. |
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
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
— provide the basic resources. | heard that measures are ‘in place’ for this situation to be services. unstructured. There was insufficient discussion with Mr Saxby. Mr Saxby’s best interest. excellence. them within 36 hours of each other. (1) There are basic requirements for Staffing and resources for a vascular hub. Royal Sussex County Hospital does not meet these requirements. As a result of this failing it was necessary for Mr Saxby to be transferred to another hub ~ at Inquest | heard that this was an almost unheard of transfer. It is unacceptable that a vascular hub does not meet the basic requirements and remedied, but in my view that is not good enough. There is no guarantee that in a weeks time another Mr Saxby will not appear on a Friday afternoon or evening and require the full resources that he should receive but find they are not available. Resources may be reduced but that is not an excuse for providing unsafe In addition, the decision to transfer Mr Saxby to St George’s was delayed and on arrival at St George’s the start of thrombolysis was also delayed. After Mr Saxby received his thrombolysis at St George’s, it became clear that the discussion about what should happen to him next was completely None of those involved in his case demonstrated any sense of urgency. Having had one ‘most unusual’ transfer from hub to hub there was apparently no thought that another ‘most unusual’ transfer from hub to hub might not be in The essence of the first transfer is to ensure the patient is transferred from Spoke to hub speedily so they can receive specialist care in a centre of There should never need to be a hub to hub transfer and certainly not two of § ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths AND your organisation have the power to take such action. and | believe you 7 YOUR RESPONSE VERONICA HAMILTON-DEELEY DL, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove THE CORONER’S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 3QB Assistant Coroners CELE Telephone: Brighton (01273) 292046 CATHARINE PALMER LL.B (HONS) Fax: Brighton (01273) 292047 KAREN HENDERSON, BSC,BM,MRCPI,FRCA GILVA D.J.TISSHAW, BA(LAW)HONS You are under a duty to respond to this report within 56 days of the date of this ‘report, namely by 25" February 2018 |, the Coroner may extend the period.
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, 2017-0365
- 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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