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recurance

John Dack

19 Feb 2015 · Coroner ME Hassell · London Inner (North)

The coroner's concerns

  1. 1. inappropriate discharge home following MDT meeting

    “Mr [name redacted] was not called for follow up because his medical notes recorded the wrong address for him, despite the fact that one of his daughters had notified staff of this on two separate occasions. What seems at first blush to be a relatively unimportant administrative matter can therefore have serious consequences. I heard from the surgeon treating Mr [name redacted] that this has happened before with other patients. It seems that this part of the system of administration would benefit from review.”

Responses

2015-0151-Response-by-Barts-Health-NHS.pdf ↗· Barts Health

Stated action

“We have asked the ward matron to speak to her staff to remind them of the importance of accurately changing patient details and the consequences of not doing so.”
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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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John Dack · Recurance