“The failures identified in the clinical review and PPO reports were, in my view, deeply…”
Dated 8 May 2019, from the coroner for Inner South London. 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
Deadline passedReplies were due by 3 Jul 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 dated8 May 2019
- Deadline3 Jul 2019
- Published on judiciary.uk8 May 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 |
|---|---|
| Oxleas NHS Foundation TrustNamed in the report as “Oxleas NHS Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 3 Jul 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.
— The failures identified in the clinical review and PPO reports were, in my view, deeply troubling. That said | am encouraged by the cooperation and efforts made by Oxleas and SERCO to formulate a policy to deal with medical emergencies falling outside the Code Red and Code Blue scenarios. However | remain concemed that a practising expert in Emergency Medicine has not yet had input into the formulation of the policies promulgated by the joint meeting between SERCO and Oxleas. In particular my concern is that there may be medical emergencies which do not fall within Code Red or Code Biue but may, nonetheless, require immediate transfer to hospital within less than an hour. It is possible that an expert in emergency medicine would be able to easily identify whether or not there are residual cases within this category. | am therefore of the view that | am under a duty to report this residual concern to Oxleas NHS Foundation Trust in order to take appropriate action, if so advised by an expert Consultant in Emergency Medicine, to reduce the risk of fatalities in future.
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, 2019-0488
- 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