“ There is limited evidence to date of improved communication, and a stronger working…”
Dated 6 Jul 2023, from the coroner for 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 31 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 dated6 Jul 2023
- Deadline31 Aug 2023
- Published on judiciary.uk7 Jul 2023
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Nottinghamshire Healthcare 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
– There is limited evidence to date of improved communication, and a stronger working relationship, between the stroke team and the neurosurgical team at the Trust There is limited evidence to date of the Stroke team having a clear understanding of the NICE guidance regarding Decompression Craniectomy, specifically the importance of detailed careful monitoring post stroke, with clarity about referral criteria to Neurosurgery. The planned Standard Operating Procedure, which may set out this clarity is not yet finalised. There are currently limited opportunities for joint case discussion and learning between the Stroke and Neurosurgical teams. The Interventional Neuroradiologists could of course also usefully participate in such Educational opportunities - I note it was , (Consultant in Interventional Neuroradiology) rather than the Stroke team, who asked that Gordon was reviewed by the Neurosurgical team on the early evening of the 7th June 2022 I am not reassured that necessary actions to address these serious issues identified are in place.
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, 2023-0230
- 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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