“Mrs Leake received treatment from three hospital teams: cardiology, cardiothoracic…”
Dated 16 Dec 2024, from the coroner for Staffordshire and Stoke-on-Trent. 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 publishedReplies were due by 10 Feb 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 dated16 Dec 2024
- Deadline10 Feb 2025
- Published on judiciary.uk27 Dec 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| University Hospitals of North Midlands NHS Trust | Response publishedPublished on judiciary.uk in December 2024. |
The coroner’s concerns
– (1) Mrs Leake received treatment from three hospital teams: cardiology, cardiothoracic surgery and coronary intensive care. Each team uses their own ward-based medical notes which are not accessible by the other teams. Whilst each team has access to the iPortal system on which Mrs Leake’s MDT decision was stored, it was apparent that this was not accessed and acted upon. As a result, the MDT decision regarding Mrs Leake’s ICD was overlooked. (2) Plans to introduce electronic patient records to which all medical teams have access are still at an early stage and no date has been identified for moving over to a single electronic notes system. (3) The steps which the Trust has taken as a result of Mrs Leake’s death to address the risk of MDT decisions being missed in the future still rely upon the manual transcription of decisions from one set of medical notes to another, with the continuing potential for human error and important decisions about treatment being overlooked.
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, 2024-0696
- 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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