“Regulation 28 – After Inquest Document Template Updated 30/07/2021 (1) The evidence…”
Dated 22 Oct 2024, from the coroner for Cambridgeshire and Peterborough. 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
All responses publishedOrganisations 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 dated22 Oct 2024
- Deadline17 Dec 2024
- Published on judiciary.uk24 Dec 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| North West Anglia NHS Foundation TrustNamed in the report as “NORTH WEST ANGLIA NHS FOUNDATION TRUST” | Response publishedPublished on judiciary.uk in December 2024. |
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The coroner’s concerns
Regulation 28 – After Inquest Document Template Updated 30/07/2021 (1) The evidence revealed that there is currently no method for ensuring that routine CT scan reports are reviewed by clinicians. This is despite a similar occurrence in May 2021. The inquest heard that the Trust are investigating a new IT System which will be able to flag when such issues occur. However this is a medium/long term project with no current completion date known and there is no system in place at present to prevent a repeat of such an incident.
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, 2024-0693
- 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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