“During the inquest I heard that the process by which the SALT team notified the ENT…”
Dated 21 Apr 2023, from the coroner for Gwent. 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 publishedOrganisations 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 dated21 Apr 2023
- Deadline16 Jun 2023
- Published on judiciary.uk23 Jun 2023
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Aneurin Bevan University Health Board | Response publishedPublished on judiciary.uk in June 2023. |
The coroner’s concerns
- During the inquest I heard that the process by which the SALT team notified the ENT department of the change in Maria’s presentation and the development of dysphagia was through an internal postal system. Following assessment by SALT on 4/5/2020, a letter was written to the ENT team which was printed and left in a pigeon hole. No evidence was forthcoming to describe a system whereby urgent matters would be brought immediately to the attention of the referring team and there was no process for ensuring that the post was dealt with in a timely manner. In Maria’s case there appears to have been a delay of a month between the letter being sent and being noticed by the ENT team.
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, 2023-0205
- 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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