“There is an inconsistency between – Previous Public Health England and current NHS…”
Dated 29 Jun 2023, from the coroner for Avon. 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 24 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 dated29 Jun 2023
- Deadline24 Aug 2023
- Published on judiciary.uk10 Aug 2023
- Today22 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| UK Health Security Agency | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 24 Aug 2023. A reply may have been sent and not yet published. |
The coroner’s concerns
– 1. There is an inconsistency between – Previous Public Health England and current NHS guidance only to notify patients undergoing surgery from January 2013 of the risk of Mycobacterium Chimaera infection And Evidence of patients contracting Mycobacterium Chimaera infection from surgery substantially earlier than January 2013 (at least as far back as 2008); 2. There appears to be no current basis for maintaining a start date of surgery in January 2013 for patient risk notification when there is evidence of infection substantially earlier than this date; 3. Patients who have contracted Mycobacterium Chimaera infection from surgery before January 2013 may be suffering a delay in diagnosis and consequent harm as a result of a lack of notification due to the existing guidelines. The Coroner's Court Old Weston Road Flax Bourton BS48 1UL
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, 2023-0286
- 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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