“A lack of robust patient pathway to ensure that all patient factors relevant to the…”
Dated 23 Dec 2021, from the coroner for Nottingham City and Nottinghamshire. 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
Deadline passedReplies were due by 17 Feb 2022. 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 dated23 Dec 2021
- Deadline17 Feb 2022
- Published on judiciary.uk29 Dec 2021
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Nottingham University Hospitals NHS Trust | 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
1. A lack of robust patient pathway to ensure that all patient factors relevant to the clinical indication for, and safety of, ERCP are identified in advance of the procedure and discussed with the patient. 2. A lack of robust system for the recording of vetting of the procedure, capturing what information has been considered as part of this process. 3. Consent is not personalised, contrary to recommendations made by the ESGE in December 2019. 4. A Lack of accountability between professionals for ensuring robust vetting and consent.
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, 2021-0432
- Added to Minute Book
- 8 Oct 2026
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- 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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