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recurance

Forgotten biliary stent without registry

Closely relatedConfidence 0.90 · high2 reports · 2018–2022No published response to an earlier report One-page brief (print or PDF)

Department of Health and Social Care received 2 coroners' reports about this hazard between 28 Jun 2018 and 18 Jul 2022.

They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.

A published response was found for 1 of the 1 earlier reports, stating 2 specific actions.

2
reports
2
different coroners
2018–2022
years
0.90
lowest link confidence

The story, report by report

Spacing grows with the time between reports.

  1. First warning

    Stephen Whitehead↗

    28 Jun 2018 · Lisa Hashmi · Manchester (North)

    “The absence of a national 'safety-netting' system (stent registry), akin to that already established for ureteric stents (a web-based registry). There is no equivalent for biliary stents.”
    Original on judiciary.uk ↗

    Department of Health and Social Care responded.Response (PDF) ↗Response (PDF) ↗

  2. 4 years 1 month later

    Raised again · 1st time

    Graham White↗

    18 Jul 2022 · Graeme Irvine · East London

    Closely relatedConfidence 0.90 · higha different coroner
    “Trust did not have in place a registry of those fitted with stents that would facilitate monitoring and recall of patients.”
    Original on judiciary.uk ↗

    Repeated from the earlier report:registrystents

    Department of Health and Social Care responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗

    “The Care Quality Commission (CQC) inspected the Barking, Havering and Redbridge University Trust in November 2021 where the Urgent Care and Emergency Services (UEC) at the Queen's Hospital were inspected. Concerns were identified and the Trust worked with local system partners to create an action plan to address these. CQC intends to inspect the UEC at the Queen's Hospital again and will consider the Trust's response to the Coroner in these inspection plans. In the meantime, CQC will monitor the”
    “We agree that ensuring patients and their GP are aware of the potential symptoms from stents, including symptoms mimicking urinary tract infection (UTI), as well as confirmed symptomatic microbiologically confirmed UTI that could be caused by a stent.”
  3. All reports to Department of Health and Social Care

Next

This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.

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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