“Despite undertaking a patient safety incident investigation (“PSII”) the Trust was unable…”
Dated 19 Sep 2024, 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
Deadline passedReplies were due by 14 Nov 2024. 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 dated19 Sep 2024
- Deadline14 Nov 2024
- Published on judiciary.uk19 Sep 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 & Redbridge University Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 14 Nov 2024. A reply may have been sent and not yet published. |
The coroner’s concerns
– 1. Despite undertaking a patient safety incident investigation (“PSII”) the Trust was unable to explain why Mr Long was not referred to the vascular team after he was admitted from ED into the medical receiving unit (“MRU”) on the morning of 2nd July 2023. The Trust struggled to identify the consultant in charge of Mr Long’s treatment when on the MRU and could not demonstrate that the consultant was spoken to as part of the PSII investigation. The inadequate standard of the investigation makes the court doubt the effectiveness of the Trust to identify and reflect upon future risks to patients. 2. Although an action plan had been agreed by the Trust to remediate the failures in care that led to the delayed referral, no clear evidence of change was demonstrated to the court.
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, 2024-0503
- 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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