“S are as follows: Concern 1: The Trust’s new policy is concerned with ensuring that…”
Dated 20 Jul 2023, from the coroner for City of 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
All responses publishedReplies were due by 14 Sep 2023.
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; a reply may have been sent and not yet published.
- Report dated20 Jul 2023
- Deadline14 Sep 2023
- Published on judiciary.uk21 Jul 2023
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Barking, Havering and Redbridge University Hospitals NHS Trust | Response publishedPublished on judiciary.uk in July 2023. |
The coroner’s concerns
S are as follows: Concern 1: The Trust’s new policy is concerned with ensuring that unexpected cancer or other critical radiological findings are highlighted to the requesting team. However, the evidence at the inquest suggested that requesting team were not alerted to the suspicious outcome of the Deceased’s November 2020 scan because it was an expected finding; as stated above, I was told that the radiologist’s report was not escalated or alerted to the clinical or multi-disciplinary teams because the requesting form had indicated that the scan was to rule out malignancy and the outcome was not, therefore, treated as unexpected. I am concerned, therefore, that the same could happen again, despite the changes which have been made. I did not consider that was able to address this concern satisfactorily in his evidence. Concern 2: The new electronic system is introducing a “read receipt” feature which, if used, would enable identification of reports which have not been opened and read by the requesting team in a timely manner. I am concerned, however, that the use of the read receipt is optional as this will inevitably undermine the extent to which any monitoring system will be able to spot and identify unread reports. I did not consider that either , nor the Consultant Colorectal Surgeon from whom I heard evidence about the plans for monitoring in the surgical department of Queens Hospital, were able to address this concern satisfactorily in their evidence.
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, 2023-0260
- 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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