“2 (1) Patients that leave the hospital Accident and Emergency Department with outstanding…”
Dated 27 Oct 2023, from the coroner for Inner West 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 22 Dec 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 dated27 Oct 2023
- Deadline22 Dec 2023
- Published on judiciary.uk11 Dec 2023
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| NHS England | Response publishedPublished on judiciary.uk in December 2023. |
| Chelsea and Westminster Hospital NHS Foundation TrustNamed in the report as “Chelsea and Westminster Hospital” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 22 Dec 2023. A reply may have been sent and not yet published. |
The coroner’s concerns
2 (1) Patients that leave the hospital Accident and Emergency Department with outstanding blood results or other diagnostic tests are not followed up and “tracked” in the same way that in-patients are, thus giving rise to the risk that they are missed and urgent follow-up care is not actioned or offered. (2) That as reliance on Accident and Emergency departments for routine out of hours health care increases, the burden of call back also increases on hospitals for patients who have left at a time when their departments are already over-stretched in dealing with admissions and those presenting to the department, thus increasing the risk that patients will not be called back for urgent follow-up assessment or treatment which may be life-saving. (3) That the system remains heavily dependent on oral handover, which is not amenable to independent audit as it assumes a person has done what was asked of them. Short of an individual doctor being asked if the call back had been actioned, there is no way of checking that it has. (4) That a periodic clinician led review of all abnormal blood results (and other test results), which the hospital has explored since I raised the matter in the hearing has not been fully implemented giving rise to the risk that patients who have left the hospital with potentially life-threatening conditions suggested by the tests may not be contacted urgently asking them to return thus increasing the risk of their untimely deaths.
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, 2023-0502
- 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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