“Cumulative delays in the execution of diagnostic processes and treatments of the patient…”
Dated 29 Sep 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 24 Nov 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 Sep 2023
- Deadline24 Nov 2023
- Published on judiciary.uk5 Oct 2023
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Barking, Havering and Redbridge University Hospitals NHS TrustNamed in the report as “Barking, Havering and Redbridge University Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 24 Nov 2023. A reply may have been sent and not yet published. |
The coroner’s concerns
1. Cumulative delays in the execution of diagnostic processes and treatments of the patient probably increased the risk of Mrs Luckraft developing biliary sepsis. 2. Following the duodenal perforation suffered by the patient there was a failure to promptly escalate her care to a high dependency unit despite her NEWS score of 8. 3. The fragmentation of the patient's treatment across two sites of the Trust contributed to delays in her treatment. 4 . The absence of a clear and workable treatment pathway fro biliary sepsis contributed to delays.
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, 2023-0355
- Added to Minute Book
- 8 Oct 2026
- Reuse
- 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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