“The length of the post procedure observation period where there has been an episode of…”
Dated 31 Jul 2019, from the coroner for Stoke-on-Trent and North Staffordshire. 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 dated31 Jul 2019
- Deadline25 Sep 2019
- Published on judiciary.uk18 Oct 2019
- Today23 Oct 2026
Watch this report
We’ll email you when a response is published on judiciary.uk, or when the 56 days to reply end with none published there yet. Free, and you can stop with one click.
Responses from each recipient
| Sent to | Response |
|---|---|
| University Hospitals of North Midlands NHS TrustNamed in the report as “University Hospital of North Midlands” | Response publishedPublished on judiciary.uk in October 2019. |
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.
— (1) The length of the post procedure observation period where there has been an episode of vomiting in the absence of any other symptoms and normal observations. (2) The pre and post procedure written documentation in respect of the advice to seek further medical attention if vomiting developed post procedure upon discharge from hospital. In evidence at inquest, the treating Consultant Pancreatico-biliary Surgeon advised that he understood the family’s confusion surrounding the symptom of vomiting given the fact that Mrs Borgogno had vomited after the procedure but had been discharged from hospital. He advised that he would recommend that the hospital review its pre and post procedure ERCP documentation provided to patients.
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, 2019-0286
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
Something wrong, such as a date or who it was sent to? Report a mistake
Is this report about someone close to you? You can ask us to remove names from our pages.
Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
Ask about this report
AISummaries and questions, with page references. Pro and above.
Sign in to use