“Consultant’s undertaking ward rounds allowed very junior doctors to make the entry from…”
Dated 30 Sep 2024, from the coroner for Inner North 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 25 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 dated30 Sep 2024
- Deadline25 Nov 2024
- Published on judiciary.uk30 Sep 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| University College London Hospitals NHS Foundation Trust | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
The coroner’s concerns
1) Consultant’s undertaking ward rounds allowed very junior doctors to make the entry from these consultations in the patient records. While there is no concern about this per se, there were numerous key factors missing from these notes. I am concerned that the notes did not fully represent the discussions and assessments that took place, which creates risk. 2) There were other omissions from the medical records for Miss Dean’s admission. 3) The on-call surgeon used language such as having “pushed the family” into agreeing to surgery on 24 August 2023. There was also evidence that not all options/possibilities were discussed with Miss Dean’s parents prior to their consenting to surgery. The evidence was that Miss Dean’s parents may not have fully understood the rationale for surgery or the possibility of conservative management of the issue, prior to the laparotomy on 24 August 2023.
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, 2024-0517
- 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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