“. The matters of concern are as follows: 1”
Dated 24 May 2022, 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
Deadline passedReplies were due by 19 Jul 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 dated24 May 2022
- Deadline19 Jul 2022
- Published on judiciary.uk24 May 2022
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| The Queen Elizabeth Hospital, King's Lynn, NHS Foundation TrustNamed in the report as “Queen Elizabeth Hospital King’s Lynn NHS Foundation 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
. The matters of concern are as follows: 1. The ED was busy at the time and unable to offload ambulances. An x-ray cannot be carried out on an ambulance and must wait until the patient is in ED. If the patient remains on the ambulance for several hours this can delay the x-ray taking place. 2. The need for an x-ray remains with the nurse, nurse in charge and/or doctor. If an xray is not carried out, the request remains with the nurse, nurse in charge and/or doctor and it was not clear from the evidence there is anything in place to ensure this is escalated and the x-ray takes place. This is something that can be missed in a busy department. 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 18 July 2022. I, the coroner, may extend the period.
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, 2022-0153
- Added to Minute Book
- 8 Oct 2026
- Reuse
- 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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