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David Birtwistle

18 Apr 2017 · Coroner Terence Moore · Avon
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The coroner's concerns

  1. 1. lack of national review of serious incidents and near misses in front door services

    “Anational review of serious incidents and near misses in similar "front door" services should happen as a matter of some urgency in order to identify common themes that can inform future service design”

  2. 2. delayed or non-user-friendly information sharing between NHS 111 and ED departments

    “NHS 111 should share information with ED departments immediately. This needs to be in a user friendly format”

Responses

Birtwistle-2017-0139a.pdf ↗

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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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