Recurance · prevention of future deaths reports
Pre-inquest brief
Forgotten biliary stent without registry
The earlier warning
Stephen Whitehead · 28 Jun 2018 · Lisa Hashmi, Manchester (North)
“The absence of a national 'safety-netting' system (stent registry), akin to that already established for ureteric stents (a web-based registry). There is no equivalent for biliary stents.”
What was promised
A published response was found, but no specific action could be extracted with a verified quote.
What recurred
- 18 Jul 2022 · Graham White · Graeme Irvine · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Stephen Whitehead · 28 Jun 2018
“The absence of a national 'safety-netting' system (stent registry), akin to that already established for ureteric stents (a web-based registry). There is no equivalent for biliary stents.”
Later · Graham White · 18 Jul 2022
“Trust did not have in place a registry of those fitted with stents that would facilitate monitoring and recall of patients.”
What happened next
No web check of the stated actions has been published for this chain.