“Following a thorough investigation, LHCH recognised that the leak was not identified on…”
Dated 12 May 2021, from the coroner for Manchester South. Sent to 2 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
All responses publishedReplies were due by 7 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 dated12 May 2021
- Deadline7 Jul 2021
- Published on judiciary.uk18 May 2021
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Medica Reporting Ltd | Response publishedPublished on judiciary.uk in May 2021. |
| Liverpool Heart and Chest Hospital NHS Foundation TrustNamed in the report as “Liverpool Heart and Chest Hospital” | Response publishedPublished on judiciary.uk in May 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) Following a thorough investigation, LHCH recognised that the leak was not identified on the CT scans in 2019 and 2020 because 3D reconstruction was not used when they were reported. LHCH have amended their reporting protocol for aortic stent surveillance accordingly and requested that Medica, who continue to report such scans for LHCH, do the same. However, as of date of the inquest, LHCH had received no response from Medica and could not assure me that Medica are using 3D reconstruction to report this type of scan and/or intend to do so in future. (2) I am therefore concerned that other patients at LHCH with aortic stents remain at risk of leaks not being identified, potentially depriving them of elective surgical management before life threatening complications occur.
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, 2021-0153
- 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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