“are in relation to the role of the HSIB in their conduct, investigation and conclusion: 3…”
Dated 20 Apr 2020, from the coroner for Surrey. Sent to 4 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 15 Jun 2020. 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 dated20 Apr 2020
- Deadline15 Jun 2020
- Published on judiciary.uk18 May 2020
- Today27 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Health Services Safety Investigations BodyNamed in the report as “HSIB” | Response publishedPublished on judiciary.uk in May 2020. |
| Department of Health and Social CareNamed in the report as “Department of Health” | Response publishedPublished on judiciary.uk in May 2020. |
| NHS England | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| East Surrey Hospital | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
The coroner’s concerns
are in relation to the role of the HSIB in their conduct, investigation and conclusion: 3 RT4563 1. The HSIB specifically requested the Trust not to undertake their own investigation effectively preventing the recognition of causes of concern and therefore being unable to undertake any immediate and necessary remedial action at the earliest opportunity to prevent future deaths. 2. HSIB indicated to the Trust at the outset that their investigation would take approximately six months which is highly likely to delay the introduction of any immediate necessary measures by the Trust to prevent further deaths. 3. The initial draft report contained factual errors and inaccuracies requiring considerable input by the Trust to resolve. The final report is insufficiently detailed and was completed 18 months after the death, during which time further deaths could have resulted. Consideration should be given to whether any steps can be taken to address the above concerns. Other matters were brought to the attention of the court outside of PFD matters which raise considerable concern as to the role and actions of HSIB which I will deal with in a letter to them in due course and will be shared with other relevant bodies.
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, 2020-0094
- Added to Minute Book
- 8 Oct 2026
- Reuse
- 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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