Sheila Creegan
10 Mar 2026 · Coroner Graeme Irvine · East London
The coroner's concerns
1. lack of investigation into death
“BHRUT chose not to investigate this case as part of NHS England's Patient Safety Framework. Mrs [name redacted] death ought to have been subject to such an investigation.”
2. governance investigation blocked
“Decisions were reached at two clinical governance meetings that meaningful learning could not flow from a governance investigation into the circumstances of Mrs [name redacted] care.”
3. inaccurate cause of death
“The inaccurate cause of death initially offered by the Trust”
4. failure to investigate infection source
“The failure to investigate the seat of Mrs [name redacted] burgeoning infection after her pneumonia resolved”
5. missed infective endocarditis diagnosis
“The missed diagnosis of infective endocarditis”
6. failure to monitor heart failure
“The failure to monitor the development of Mrs [name redacted] heart failure during her inpatient treatment”