David Marriott
3 Jun 2026 · Coroner Laurinda Bower · Nottingham and Nottinghamshire
The coroner's concerns
1. missed follow up chest x-ray for high-risk CAP patients
“Ensure all ED staff are familiar with the British Thoracic Society Guidelines (advising follow up chest x-rays for patients diagnosed with community acquired pneumonia in the presence of risk factors), and ensure the discharging doctors know how to arrange the same for patients being discharged from ED”
2. lack of radiology report review post discharge
“A failure to have in place a system for reviewing radiology reports that arrive after the patient has been discharge from ED”
3. inadequate discharge summaries causing patient safety risk
“Poor quality discharge summaries, a failure to have in place a system for quality assurance, and a failure to share summaries with patients”