“Regulation 28 – After Inquest Document Template Updated 30/07/2021 1”
Dated 25 Mar 2024, from the coroner for Nottingham City and Nottinghamshire. 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 publishedOrganisations 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 dated25 Mar 2024
- Deadline20 May 2024
- Published on judiciary.uk13 Aug 2024
- Today27 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Nottinghamshire Healthcare NHS Foundation Trust | Response publishedPublished on judiciary.uk in August 2024. |
The coroner’s concerns
Regulation 28 – After Inquest Document Template Updated 30/07/2021 1. Inadequate review and incident investigation following a death Following Mr Lyalushko’s death, Nottinghamshire Healthcare NHS Foundation Trust completed an SI Review by way of case note review. Following evidence which considered the content of that review, the Trust stated that the review was ‘insufficient in its current form and the scope should be broadened to include the concerns raised (during the inquest hearing).’ The Trust said its Patient Safety Investigation Lead would undertake a new SI Review by 26 April 2024 (6 weeks). I identified a number of deficiencies with the initial SI Review which had been undertaken in respect of Mr Lyalushko: it did not identify that a request from Mr Lyalushko’s GP in November 2022 for involvement of its service with Mr Lyalushko had not been actioned; it incorrectly identified areas where improvements were required as areas of good practice; and it did not involve any level of consultation with Mr Lyalushko’s family to consider whether there were any areas of concern they had which might direct elements of the review. If there is insufficient review and learning from a death that, in my judgment, adds to the likelihood of future deaths occurring in similar circumstances. I am not reassured that necessary actions to address the serious issue identified i.e. inadequate initial review and incident investigation following a death, are yet in place.
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, 2024-0449
- 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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