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recurance

Susan Roberts

7 Jun 2021 · Coroner Dr Anthony Howard · West Yorkshire Western Division

The coroner's concerns

  1. 1. lack of timely and effective hand over between surgical specialties

    “lack of timely and effective hand over been the different surgical specialties, with an absence of formal protocol”
  2. 2. lack of engagement from Plastic Surgeons

    “lack of engagement from the Plastic Surgeons. They failed to join the Orthopaedic Registrar in theatre at the time of the incident and then failed to attend the round table analysis at part of the SI investigation”

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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