“6 (1) There is no requirement for a section 10 exempt entity to report any of its…”
Dated 15 Nov 2024, from the coroner for Inner South 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
All responses publishedReplies were due by 10 Jan 2025.
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; a reply may have been sent and not yet published.
- Report dated15 Nov 2024
- Deadline10 Jan 2025
- Published on judiciary.uk15 Nov 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Department of Health and Social Care | Response publishedPublished on judiciary.uk in November 2024. |
| NHS England | Response publishedPublished on judiciary.uk in November 2024. |
| Care Quality Commission | Response publishedPublished on judiciary.uk in November 2024. |
| Medicines and Healthcare products Regulatory AgencyNamed in the report as “Medicines, and Healthcare Products Regulatory Agency” | Response publishedPublished on judiciary.uk in November 2024. |
The coroner’s concerns
– 6 (1) There is no requirement for a section 10 exempt entity to report any of its findings to the MHRA or indeed to other Trusts or the industry in general if an adverse event occurs. (2) The current reporting structures (for a section 10 entity) involve reporting to NHSE and the CQC but the threshold or necessity for such reporting appears unclear and, in essence, up to the Trust. (3) There may be times when section 10 entities reach conclusions which would assist the wider industry and help to assist both other Trusts and commercial organisations in assessing their own risks and improving the provision of highly specific medication to a group of vulnerable patients. (4) the same may also be true of commercial organisations but they have the power of the MHRA controlling and effecting recalls and actions and the wider dissemination of information.
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, 2024-0628
- 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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