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recurance

Thomas Dixon

8 Jul 2014 · Coroner Derek Winter · Sunderland

The coroner's concerns

  1. 1. delayed follow up appointment

    “There was a failure to give Mr [name redacted] an appointment 6 months after he was seen in August 2012”
  2. 2. missed urgent procedure

    “There was a failure to give Mr [name redacted] an urgent appointment for a procedure within 4-6 weeks of the 14/08/2013”
  3. 3. missing referral documentation

    “Important documentation was missing namely the referral form for the procedure that Civic Centre, Burdon Road”
  4. 4. lack of monitoring systems

    “There appeared to be no systems in place to identify and take action to rectify these problems”

Responses

No published response was found on judiciary.uk.

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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.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error