Recurance · prevention of future deaths reports
Pre-inquest brief
Recurring hazard (see the quoted concerns)
The earlier warning
Maria Lopes · 11 Jul 2014 · Karen Henderson, Surrey
“The recognition and treatment of sepsis as per national guidelines”
What was promised
A published response was found, but no specific action could be extracted with a verified quote.
What recurred
- 4 Jul 2024 · David Morris · Graeme Irvine · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Maria Lopes · 11 Jul 2014
“The recognition and treatment of sepsis as per national guidelines”
Later · David Morris · 4 Jul 2024
“During the evening of 3rd May 2022 going into the early hours of 4th May 2022, Doctors and nurses failed to identify the extent of Mr [name redacted] gastrostomy leak and the onset of sepsis.”
What happened next
No web check of the stated actions has been published for this chain.