“Mr Morris’s diagnosis and treatment for cancer was delayed due to poor organisation and…”
Dated 4 Jul 2024, from the coroner for East London. Sent to 3 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
All responses publishedReplies were due by 29 Aug 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 dated4 Jul 2024
- Deadline29 Aug 2024
- Published on judiciary.uk4 Jul 2024
- 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” | Response publishedPublished on judiciary.uk in July 2024. |
| Department of Health and Social Care | Response publishedPublished on judiciary.uk in July 2024. |
| Medicines and Healthcare products Regulatory AgencyNamed in the report as “Medicine and Healthcare products Regulatory Agency” | Response publishedPublished on judiciary.uk in July 2024. |
The coroner’s concerns
– 1. Mr Morris’s diagnosis and treatment for cancer was delayed due to poor organisation and communication at the Trust. 2. During the evening of 3rd May 2022 going into the early hours of 4th May 2022, Doctors and nurses failed to identify the extent of Mr Morris’s gastrostomy leak and the onset of sepsis. After identifying symptoms of sepsis, staff failed to treat and escalate Mr Morris’s care resulting in a delay of three and a half hours before a medical review commenced emergency treatment. 3. During Mr Morris’s ward-based treatment on 3 & 4th May 2022 clinical records were either of a poor standard or were non-existent. The absence of clear records impeded the effective investigation of this death by the Trust’s governance teams and the Coroner. 4. The initial serious investigation report into Mr Morris’s death was unfit for purpose. The report to investigate or even identify the Registrar who reviewed Mr Morris on the evening of 3rd May 2022. Since then, no effective review has been undertaken by the Trust upon how this deficient report gained executive approval. 5. The Trust did not have effective controlled drug management systems in place to detect a prolonged and persistent course of conduct from an employed nurse who was stealing and self- administering controlled drugs in the workplace.
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, 2024-0360
- 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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