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recurance

Joan Richardson

23 Jun 2014 · Coroner David Hinchliff · West Yorkshire (East)

The coroner's concerns

  1. 1. staff training

    “It is correct and appropriate for GP practices to have dedicated time for staff training”
  2. 2. unavailable doctor during emergency

    “On the occasions where there is a genuine emergency as there clearly was here, a Doctor should be available to deal with such an emergency notwithstanding that the surgery is closed for routine work, particularly when the training session is within normal surgery hours”
  3. 3. inconsistent emergency protocols

    “This is an obvious issue for the Fountain Medical Centre but should also be addressed by all GP practitioners, hence the Leeds West Clinical Commissioning Group being incorporated within this Report to ensure that all GP practices adopt the same system”
  4. 4. delayed referral

    “No criticism is made that a precise diagnosis was not made. Nevertheless had Ms [name redacted] been seen on the 21° November 2013 it would have been obvious that she was extremely unwell and that her presentation was urgent and that time was of the essence and that she should have been referred to hospital immediately”
  5. 5. 24 hour delay

    “The delay of almost 24 hours has been a contributory factor”

Responses

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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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