“That there is no method of noting in the medical records that a salivary bypass tube is…”
Dated 7 May 2021, from the coroner for Norfolk. 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 2 Jul 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 dated7 May 2021
- Deadline2 Jul 2021
- Published on judiciary.uk7 May 2021
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Norfolk and Norwich University Hospitals NHS Foundation TrustNamed in the report as “Norfolk and Norwich University Hospital NHS Foundation Trust” | Response publishedPublished on judiciary.uk in May 2021. |
The coroner’s concerns
That there is no method of noting in the medical records that a salivary bypass tube is in the patient’s body. That this death happened nearly nine months ago and still there is no method of showing staff in the notes that a patient has this prosthesis and that no thought had been given to this simple measure e.g. a rubber stamp stating patient has a bypass tube in situ to be ticked and signed. The hospital already uses this method for when an intravenous cannulae is inserted and hip prosthesis. This is immediately noticeable and would alert staff. That the quality of the documentation pre and post operatively is of poor quality and would not assist other staff to find out what treatment had been given. That there is nowhere on the consent form or the anaesthetic checklist for the presence of a tube to be asked about and documented. These are basic common-sense measures which should have been in place. Had the absence of the tube been noted when it was only in the stomach it is likely that Mr Slope would not have died months later from a perforated small bowel. That the clinical specialist nurses did not contact anyone or document the concerns raised by Mr Slope in March 2020. That the hospital did not request a summary of Mr Slope’s treatment at a different hospital before commencing the procedures, this could easily be requested via e mail.
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, 2021-0144
- 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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