“There was a lack of thorough history taking and a number of assumptions were made on the…”
Dated 13 Jun 2023, 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
Deadline passedReplies were due by 8 Aug 2023. 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 dated13 Jun 2023
- Deadline8 Aug 2023
- Published on judiciary.uk22 Jun 2023
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Barts Health NHS TrustNamed in the report as “Barts Health NHS Foundation Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 8 Aug 2023. A reply may have been sent and not yet published. |
The coroner’s concerns
1. There was a lack of thorough history taking and a number of assumptions were made on the basis of Raquel’s high BMI. There was an assumed chronic low oxygen saturation with no evidence that the doctors had checked the records available or asked the patient about her baseline. The oxygen saturations recorded in the Barts sleep apnoea clinic in 2015 and 2016 were noted to be 99% and 100%. 2. There was a lack of escalation of monitoring following the NEWS score of 10. It is of concern that the NEWS policy was not complied with by the nursing staff. 3. There was disagreement between senior clinicians as to how the Trust’s PE policy should have been applied. The policy is often not used in accordance with the specific wording. For example, the requirement for pleuritic chest pain is often ignored in practice. A senior clinician within the Trust considered that the caveat for pleuritic chest pain in the policy should be reviewed. In addition, the senior clinician described some of the wording in the policy as “clumsy”. In light of this, the Trust may wish to review the policy.
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, 2023-0192
- 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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