Francis Barnes
27 Oct 2023 · Coroner Heidi Connor · Berkshire
The coroner's concerns
1. lack of learning from deaths
“The focus of my concerns relates to the approach of your Trust to learning from deaths”
2. absence of electronic referral system
“Consideration of an electronic referral system (such as OARS)”
3. inadequate response to learning from deaths
“Consideration of how the Oxford Trust responds to and learns from deaths”
Responses
2023-0417-Response-from-Oxford-University-Hospitals-NHS-Foundation-Trust.pdf ↗· Oxford University Hospitals NHS Foundation Trust
Stated action · 1 January 2024
“Following this inquest, a concise procedure for contacting the Vascular Team at OUH has been developed and approved by the TVVN which clearly sets out the referral process for patients who have a vascular emergency within the Network. This will be sent to all NHS and private providers in Thames Valley and provides details on how to contact the on-call Vascular SpR and on-call Vascular Consultant.”