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recurance

Gordon Long

19 Sept 2024 · Coroner Graeme Irvine · East London

The coroner's concerns

  1. 1. delayed referral to vascular team

    “Despite undertaking a patient safety incident investigation ("PSII") the Trust was unable to explain why Mr [name redacted] was not referred to the vascular team after he was admitted from ED into the medical receiving unit ("MRU") on the morning of 2nd July 2023”
  2. 2. lack of demonstrated change

    “Although an action plan had been agreed by the Trust to remediate the failures in care that led to the delayed referral, no clear evidence of change was demonstrated to the court”

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.

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