“The inquest heard evidence that there is only one radiology list per week to accommodate…”
Dated 7 May 2024, from the coroner for Birmingham and Solihull. 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 2 Jul 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 dated7 May 2024
- Deadline2 Jul 2024
- Published on judiciary.uk14 May 2024
- Today21 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| University Hospitals Birmingham NHS Foundation Trust | Response publishedPublished on judiciary.uk in May 2024. |
The coroner’s concerns
– 1. The inquest heard evidence that there is only one radiology list per week to accommodate replacement of feeding tubes in patients with complex needs. In Peter’s case this meant he had to wait a week for the tube to be replaced meaning he had suboptimal nutrition during this period. Consideration should be given to whether additional services are required for replacement of feeding tubes in patients with complex needs. 2. The inquest heard evidence that Peter’s nutritional status was suboptimal due to repeated tube dislodgments and waiting for radiology or theatre slots to be available. Consideration needs to be given as to how best to maintain patients’ nutrition after tube dislodgments when they rely on feeding tubes.
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, 2024-0249
- 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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