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recurance

Christopher Bradbury

11 Mar 2025 · Coroner Emma Serrano · Staffordshire

The coroner's concerns

  1. 1. lack of knowledge of severe invasive soft tissue infections

    “A national lack of knowledge of Severe Invasive Soft Tissue Infections, that are not (but are closely related to) necrotising fasciitis combined with a lack of national Guidelines on this. This being exacerbated by the large number of Drs expected to specialise in this.”
  2. 2. ineffective training and actions

    “The evidence given was that, training is being delivered continuously, and the actions from the PSII have been carried out but this is not making significant inroads, it had not been effective at all, and it is thought that this will happen again.”
  3. 3. no audit trail for omitted medication

    “When signing medication out, at the hospital, if the medication is not available, no signature is required when choosing option 5”

Responses

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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.

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