“The inquest heard that nursing staff requested reviews by the on-call orthopaedic doctors…”
Dated 19 Dec 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
All responses publishedReplies were due by 13 Feb 2024.
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 dated19 Dec 2023
- Deadline13 Feb 2024
- Published on judiciary.uk28 Dec 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” | Response publishedPublished on judiciary.uk in December 2023. |
The coroner’s concerns
(1) The inquest heard that nursing staff requested reviews by the on-call orthopaedic doctors on multiple occasions, without the doctors attending to carry out a review. A junior doctor described the junior orthopaedic staffing levels in the hospital as “dangerous”. (2) The inquest heard that the NEWS charts were not available on the ward rounds. The consultants did not therefore review the charts and were unaware of the frequently raised NEWS scores. The inquest heard that laptops on the ward were unwieldy and time consuming. There were no iPads or vital packs available for the ward round team to easily access the NEWS scores. (3) The inquest heard that there was confusion between the doctors as to who was responsible for the patient, in light of her dual orthopaedic and medical needs. Orthogeriatricians were aware of Mrs Waylett’s desaturation on 19 October 2022, but appeared to have considered it necessary for them to receive a referral from the orthopaedic team before they could carry out a review.
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, 2023-0532
- Added to Minute Book
- 8 Oct 2026
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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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