“There was no apparent liaison between the teams involved in Kingsley’s care to consider…”
Dated 11 Oct 2024, from the coroner for North London. Sent to 4 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
Deadline passedReplies were due by 6 Dec 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 dated11 Oct 2024
- Deadline6 Dec 2024
- Published on judiciary.uk16 Oct 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Homerton Healthcare NHS Foundation Trust | Response publishedPublished on judiciary.uk in October 2024. |
| The British Society of Gastroenterology | Response publishedPublished on judiciary.uk in October 2024. |
| The Royal College of Radiologists | Response publishedPublished on judiciary.uk in October 2024. |
| The Royal College of Pathology | 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. There was no apparent liaison between the teams involved in Kingsley’s care to consider any matters that may be relevant to his HbSS prior to the biopsy being carried out; 2. The Trust’s Standard Operating Procedure (“SOP”) for Elective Liver Biopsy does not appear to give consideration to patients with other pathologies such as HbSS; 3. There was no apparent consideration given to potential additional post-operative monitoring or requirements for a patient with HbSS; 4. The Trust’s SOP refers to a document titled “ Guidelines on the use of liver biopsy in clinical practice from the British Society of Gastroenterology, the Royal College of Radiologists and the Royal College of Pathology ” (Neuberger J, Patel J, Caldwell H et al . Gut 2020) which provides advice on liver biopsy techniques, methods and aftercare etc. These guidelines do not appear to give consideration (and therefore guidance) in relation to the use of liver biopsy for patients with other pathologies such as HbSS.
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, 2024-0554
- 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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