Janet Seddon
14 Oct 2024 · Coroner Catherine Cundy · North Yorkshire and York
The coroner's concerns
1. missed abdominal pathology
“The Trust became aware on the 7th of February 2023 that abdominal pathology requiring urgent assessment had been missed when Mrs [name redacted] CT scan was initially reported on the 30th of January 2023”
2. delayed investigation of case
“The Trust referred Mrs [name redacted] death to the Coroner on the basis that her family was concerned about possible omissions in primary care”
3. lack of disclosure to family
“no disclosure was made to Mrs [name redacted] family of the error in accordance with the Trust's statutory Duty of Candour”
4. potential risk of death to others
“the potential risk of death to others in the event of a recurrence of any of the above”
Responses
2024-0551-Response-from-York-Scarborough-Teaching-Hospitals-NHS-Foundation-Trust.pdf ↗· York and Scarborough Teaching Hospitals NHS Foundation Trust
Stated action · 12/12/24
“The Trust moved to the new Patient Safety Incident Response Framework (PSIRF) in December 2023. Since that time revised systems and processes have been put in place to record, monitor, review and learn from incidents across the Trust. It is acknowledged that this incident should have had, under the old policy, a 72-hour report, and this was not undertaken. This has been reviewed within the Surgery Care Group and the new policy requiring either hot debrief or other form of incident response is now”