“Failure to effectively communicate key changes in clinical practice and advice e.g”
Dated 19 Jul 2019, from the coroner for South Yorkshire East. 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
Deadline passedReplies were due by 13 Sep 2019. 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 dated19 Jul 2019
- Deadline13 Sep 2019
- Published on judiciary.uk9 Sep 2019
- Today27 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Public Health England | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 13 Sep 2019. A reply may have been sent and not yet published. |
| Yorkshire and the Humber Region | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 13 Sep 2019. A reply may have been sent and not yet published. |
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.
— (1) Failure to effectively communicate key changes in clinical practice and advice e.g. an amended definition of a tetanus prone wound in the Public Health England email of July 2018 entitled Vaccine Update (attached). Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DN1 3HS Tel 01302 737135 | Fax 01302 736365 (2) Requiring Primary Care practitioners to click through a number of links and documents to try and unearth key pieces of information carries with it the risk that that information will be overlooked if key issues have not being identified in the covering email. (3) A failure generally to identify key issues in any updated in medical practice and communicate those effectively to those healthcare professionals involved in delivering such care. (4) Failure to update Green Book Guidance.
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, 2019-0248
- 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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