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Joan Knight

22 Oct 2024 · Coroner Louise Hunt · Birmingham and Solihull
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The coroner's concerns

  1. 1. inadequate learning from mortality reviews

    “The mortality review that was undertaken in this case was completed incorrectly and contained contradictory terms about whether the death was avoidable. This raises a concern that mortality reviews are not being conducted correctly and that there could be inadequate learning from cases raising a risk of future deaths.”

Responses

2024-0566-Response-from-University-Hospitals-Birmingham-NHS-Foundation-Trust.pdf ↗· University Hospitals Birmingham NHS Foundation Trust

Stated action

“We have requested that the speciality use the three methodology coding scores recommended by the Learning from Deaths Team in line with the rest of the Trust and we have disabled the use of all other methodology coding fields on the software.”
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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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Joan Knight · Recurance