“6 1”
Dated 5 Oct 2023, from the coroner for East London. Sent to 2 organisations or people.
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 30 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 dated5 Oct 2023
- Deadline30 Nov 2023
- Published on judiciary.uk18 Oct 2023
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Barts Health NHS TrustNamed in the report as “Barts Health NHS Foundation Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 30 Nov 2023. A reply may have been sent and not yet published. |
| Department of Health and Social CareNamed in the report as “Department for Health and Social Care” | Response publishedPublished on judiciary.uk in October 2023. |
The coroner’s concerns
- 6 1. The poor quality of recording clinical records impeded the Trust's governance processes, in that the author of a serious incident investigation was unable to rely on clear evidence to understand why essential actions were not carried out in Ms Fordham's care. 2. The Trust failed to complete a falls risk assessment of Ms Fordham. 3. The consequence of (2) was that no falls care plan was completed. 4. The fact that the failures at (2) & (3) were not detected and remediated by successive clinical staff members suggests that they did not read essential parts of the clinical record when providing care. The cumulative failings, on the part of multiple healthcare professionals suggests a culture of indifference inimical to the provision of safe and effective practice. 5. The Trust has not considered any step to resolve individual failings in care through disciplinary or regulatory channels.
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, 2023-0373
- 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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