“Concern 1: Contacting Specialist Centres Non-specialist medical staff may have varied…”
Dated 12 Nov 2024, from the coroner for Coventry and Warwickshire. Sent to 5 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 7 Jan 2025. 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 dated12 Nov 2024
- Deadline7 Jan 2025
- Published on judiciary.uk12 Nov 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| NHS England | Response publishedPublished on judiciary.uk in November 2024. |
| George Eliot Hospital NHS Trust | Response publishedPublished on judiciary.uk in November 2024. |
| UK Kidney Association | 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. |
| British Transplant Society | 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. |
| Renal Association | 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. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
Concern 1: Contacting Specialist Centres Non-specialist medical staff may have varied understanding of the appropriate contacts and timing for engaging with specialist renal hospitals. Concern 2: Information Sharing with Specialist Centres The specific patient information that non-specialist staff should provide to specialist renal hospitals may not always be clearly defined. Concern 3: Accessibility to Renal Care Guidelines Non-specialist staff may experience varying levels of awareness or accessibility to guidelines and protocols for treating kidney transplant patients. This could lead to a misunderstanding of the significance and urgency of the actions recommended by specialist renal hospitals. Concern 4: Transfer Responsibility There may be some inconsistency across non-specialist hospitals and renal hospitals in understanding who is responsible for initiating patient transfers. Concern 5: Decision-Making for Patient Location Considerations regarding whether patients should remain in non-specialist areas or be transferred may differ, potentially affecting consistency in care approaches. Concern 6: Coordination Between Specialist and Non-Specialist Hospitals There may be variation in how specialist renal hospitals engage with nonspecialist hospitals that rely on their expertise, impacting collaborative efforts in patient care. Currently, there is no clear guidance on how specialist and non-specialist teams should work together effectively to ensure consistent, high-quality care for these patients. 6. ACTION SHOULD BE TAKEN: In my opinion, action should be taken to prevent future deaths, and I believe you, have the power to take such action. 7. YOUR RESPONSE: You are under a duty to respond to this report within 56 days of the date of this report, namely by 7 January 2025. I, the coroner, may extend the period if necessary.
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, 2024-0618
- 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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