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recurance

Brian Havard

22 Mar 2019 · Coroner Yvonne Blake · Norfolk

The coroner's concerns

  1. 1. failure to review ambulance records before discharge

    “The doctor had not read the ambulance electronic records and was not aware of a system in place to obtain these notes prior to his seeing the patient. These notes contained information about Mr [name redacted] having hematemesis and two doses of morphine given to Mr [name redacted] by the crew. He did examine Mr [name redacted] and had differential diagnoses and went to speak to the locum consultant who was just coming on shift for advice. The consultant did not ask to see the notes from the crew or the hospital notes and”

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