“S are as follows: During the course of the evidence I heard from consultants and more…”
Dated 28 Oct 2019, from the coroner for Milton Keynes. 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 dated28 Oct 2019
- Deadline23 Dec 2019
- Published on judiciary.uk14 May 2020
- 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 |
|---|---|
| Milton Keynes University Hospital NHS Foundation TrustNamed in the report as “Milton Keynes Hospital” | Response publishedPublished on judiciary.uk in May 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
S are as follows: During the course of the evidence I heard from consultants and more junior staff that they were unaware of certain facts relating to Mr. Smyth at the time that they were dealing with him and making decisions relating to his care, and yet the information was recorded in the electronic notes and records. It appears to me that staff are having difficulty accessing vital information that should be clearly available to them. I would ask that you carry out a review of the notes system to see whether or not it is being used correctly, whether staff members have been adequately trained with regard to its use and whether changes should be made as to how information is recorded and retrieved. Unless the system is working effectively I anticipate that further lives will be put at risk. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 16 December 2019. I, 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, 2019-0505
- 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