“Telephone 01275 461920 Email AvonCoronersTeam@bristol.gcsx.gov.uk Website…”
Dated 16 Dec 2019, from the coroner for Avon. 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
All responses publishedReplies were due by 10 Feb 2020.
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 dated16 Dec 2019
- Deadline10 Feb 2020
- Published on judiciary.uk3 Jan 2020
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| University Hospitals Bristol | Response publishedPublished on judiciary.uk in January 2020. |
| Torbay and South Devon NHS Foundation TrustNamed in the report as “Torbay and South Devon NHS Trust” | Response publishedPublished on judiciary.uk in January 2020. |
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.
— Telephone 01275 461920 Email AvonCoronersTeam@bristol.gcsx.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL The evidence demonstrated that Alice was under the care of a consultant community paediatrician, a consultant general paediatrician with an interest in endocrinology and a consultant paediatric endocrinologist presenting with a number of conditions (Growth hormone deficiency, Autistic Spectrum disorder, developmental delay, visual impairment, mobility impairment, poor coordination/dyspraxia and hypermobility) over a 9 year period but was not referred for investigation of an underlying disorder, specifically a clinical geneticist’s opinion, despite her parents requesting this on at least 2 separate occasions which are documented and despite such facility being readily available in Exeter. The evidence demonstrated that as a result her underlying condition, and specifically a serious cardiomyopathy, went undiagnosed resulting in her dying unexpectedly and prematurely as a result of a routine general anaesthetic. Telephone 01275 461920 Email AvonCoronersTeam@bristol.gcsx.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action.
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, 2019-0442
- Added to Minute Book
- 8 Oct 2026
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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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