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recurance

Nicholas Winterton

31 Mar 2021 · Coroner Alison Hewitt · City of London

A similar concern from this report was raised again 1 time later. See the linked reports.

The coroner's concerns

  1. 1. inaccurate risk assessment of Mycobacterium Chimaera infection

    “it is important that the nationally recognised level of the risk of developing Mycobacterium Chimaera from exposure to a heater cooler unit is accurate, in that it accurately reflects the most current statistical data, and is based on the best gathering of statistical data as to the true incidence of such infection as can practicably be achieved. This is because the nationally recognised level of risk is the proper basis upon which - (i) The informed consent of a patient for a relevant surgery is”

Linked reports

Raised again laterClinton Fear29 Jun 2023 · 2 years 3 months later
Closely relatedConfidence 0.90 · high

This report

“It is apparent that it is important that the nationally recognised level of the risk of developing Mycobacterium Chimaera from exposure to a heater cooler unit is accurate”

Later report

“There is an inconsistency between - Previous Public Health England and current NHS guidance only to notify patients undergoing surgery from January 2013 of the risk of Mycobacterium Chimaera infection”
Original on judiciary.uk ↗
Full chain: Inaccurate risk assessment of Mycobacterium Chimaera infection from heater-cool

Responses

2021-0204-Response-from-Public-Health-England-Redacted.pdf ↗· UK Health Security Agency

Stated action · September 2021

“PHE will further update the risk estimates and ensure that these are published by September 2021”
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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