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recurance

Paula Elsley

6 Feb 2024 · Coroner Robert Simpson · Berkshire

The coroner's concerns

  1. 1. lack of accessible smoking status records

    “During the inquest I heard evidence that a patient's smoking status (current or former) was not routinely recorded by the GP practice in a manner that was immediately accessible when reviewing the medical records”
  2. 2. failure to apply NICE chest x-ray referral thresholds

    “Based on evidence heard at inquest I am concerned that at the time of [the deceased]'s death (March 2022) the same NICE guideline was not being routinely considered by GPs”

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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