“In the course of oral evidence Dr and , both Consultants in Accident and Emergency…”
Dated 28 Mar 2021, 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 publishedReplies were due by 23 May 2021.
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 dated28 Mar 2021
- Deadline23 May 2021
- Published on judiciary.uk30 Mar 2021
- 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 University Hospital” | Response publishedPublished on judiciary.uk in March 2021. |
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
– (1) In the course of oral evidence Dr and , both Consultants in Accident and Emergency Medicine at the hospital gave conflicting accounts of how much importance they would ascribe to the lactate level which was nearly twice the upper limit of normal and whether they would repeat it before discharge. told me he would not repeat it because he saw lots of patients with elevated lactate and with the resources he had available he would be spending a disproportionate amount of time checking lactate levels in patients who ultimately would be fine. We spent some time on the point and with reference to the NICE Sepsis Risk Stratification Tools. The Guideline is clear that if a lactate is above 2 then the patient should be escalated to high risk. was challenged several times on his position that irrespective of the guidelines he would not routinely repeat the lactate level dismissing it as an unnecessary burden. He maintained that position. Dr took a flatly contrary view and said that she would repeat it irrespective of the burden of work it may generate. These contrasting opinions indicate a degree of confusion amongst the senior staff at Milton Keynes University Hospital Accident and Emergency Department which in my view poses a threat to patients with sepsis and with elevated lactate levels. The disregarding of the NICE Guidelines simply because it is inconvenient is disturbing. 2
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, 2021-0087
- 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