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recurance

Nancy Rogers

9 Jul 2024 · Coroner Nicholas Shaw · Cumbria

The coroner's concerns

  1. 1. failure to implement learning from similar deaths

    “At the inquest into [name redacted] death the hospital report indicated no learning was required as her presentation was not typical. The circumstances in both these cases are remarkably similar in that both ladies attended the emergency department at Furness General and were allowed home only to die within a day of the same cause and as far as the attending clinician at today's hearing knew no learning or teaching has taken place since [the deceased]'s death.”
  2. 2. inadequate awareness of aortic dissection resources

    “As a coroner I am not permitted to suggest what actions might be taken but feel it safe to mention NHS futures Aortic Dissection Toolkit and The Aortic Dissection Charitable Trust for further information.”

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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