“The Inquest heard evidence that the Trust policy in relation to risk assessment and risk…”
Dated 20 May 2021, from the coroner for East London. 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 15 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 dated20 May 2021
- Deadline15 Jul 2021
- Published on judiciary.uk24 May 2021
- Today22 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 |
|---|---|
| North East London NHS Foundation TrustNamed in the report as “North East London Foundation Trust” | Response publishedPublished on judiciary.uk in May 2021. |
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
— The Inquest heard evidence that the Trust policy in relation to risk assessment and risk management is sufficiently clear, however the Court was not fully satisfied that the said policy had been fully embedded into practice. A number of nursing staff, including senior nursing staff, during the course of the admission, failed to follow the policy. Another concern arising during the course of the Inquest related to the integrity of the electronic records. The Inquest heard that medical records should be validated very shortly after being entered into the system. The Court saw evidence of multiple entries where there was a significant delay between original entry and validation. Amendments were made to the records after Neil had passed away, but these were not apparent on the records disclosed to the Court. An audit of the records had to be carried out before the amendments were exposed.
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, 2021-0164
- 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