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recurance

Johan Pambou

20 Apr 2017 · Coroner Louise Hunt · Birmingham and Solihull

The coroner's concerns

  1. 1. lack of monitoring and action on letters from hospitals

    “System and record keeping in the GP practice. Four letters were received asking for this child to receive pneumovax23 vaccination from February 2016 to November 2016. None of the letters were actioned by the GP. They were simply filed away.”
  2. 2. unavailability of pneumovax23 vaccine

    “Availability of ppeumovax vaccine 23. | heard evidence from the GP in this case that attempts were made to obtain the vaccine in June 2016 but it was unavailable. | was also told the vaccine continued to be unavailable now. | am concerned about the availability of the vaccine and whether GPs fully understand where to access the vaccine.”

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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