“Timely notification to ERCP practitioners following serious complications, with formal…”
Dated 30 Dec 2024, from the coroner for Suffolk. 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 24 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 dated30 Dec 2024
- Deadline24 Feb 2025
- Published on judiciary.uk17 Jan 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| East Suffolk and North Essex NHS Foundation TrustNamed in the report as “East Suffolk and North Essex Foundation Trust” | Response publishedPublished on judiciary.uk in January 2025. |
The coroner’s concerns
Timely notification to ERCP practitioners following serious complications, with formal case review ERCP-based endoscopic complications should be presented in a formal setting in the presence of Endoscopy colleagues. There is a need for timely feedback to responsible ERCP practitioners in cases of procedure-based complications to ensure checks and learning on matters such as safety and adherence to guidelines and standard practice. Regular discussions about management plans and treatment options with NOK/family by a responsible Surgical Consultant for inpatients with serious chronic surgical issues Plans and management were discussed on the Surgical ward with Dee by the Consultant but there was a paucity of comprehensible and timely communication with the next of kin and rest of the family concerning management plans and treatment options. Two-way feedback in this situation plays a vital role in maintaining patient wellbeing and safety. Lack of clarity around named Surgical Consultant cover for unexpected leave It was unclear who was the Surgical Consultant responsible for Dee and her pancreatic disease management when her usual Consultant was off work due to unexpected leave. A clear handover process at Consultant Surgeon level for unexpected leave enables continuation of care between health care professionals and teams with continuity and oversight of treatment and management plans. Accordingly, I consider that: Not having timely notification to ERCP practitioners following serious procedurebased complications, and timely associated formal ERCP case review with endoscopy colleagues Not having regular explanations and discussions with NOK/family by the responsible Consultant concerning ongoing management plans and treatment options for inpatients with serious surgical issues and, Lack of clarity over named Surgical Consultant cover with responsibility for surgical inpatients during periods of unexpected leave Regulation 28 – After Inquest Document Template Updated 30/07/2021 All pose a significant risk to patient safety.
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, 2025-0030
- 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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