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recurance

Alan Hodgson

3 Mar 2022 · Coroner Derek Winter DL · City of Sunderland

The coroner's concerns

  1. 1. administration of opiate analgesia without ascertaining necessity

    “Signing and administration of opiate analgesia to a patient without any evidence of ascertaining why such analgesia was required, and if it was appropriate”
  2. 2. failure to review patient on-call

    “Failure by the on-call Registrar to review a patient in the early hours of the morning when called for advice by the FY1 doctor”
  3. 3. failure to follow vascular pathway

    “Failure by a Consultant [name redacted] to follow an established Vascular Pathway despite clearly recognising the correct diagnosis of acute lower limb ischaemia”
  4. 4. delays in CTA

    “delays in CTA being performed”
  5. 5. inadequate imaging

    “inadequate imaging being performed”
  6. 6. lack of urgency in reporting CTA findings

    “a complete lack of urgency in reporting the findings of the CTA to the requesting doctors”

Responses

No published response was found on judiciary.uk.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error