Skip to content
recurance

Stephen Wells

5 Sept 2022 · Coroner Karen Harrold · West Sussex

The coroner's concerns

  1. 1. lack of treatment for a cancer patient

    “I heard evidence that Mr [name redacted] GP wrote two urgent letters to the RSFT consultant oncologist and HPB surgeon dated 22 September 2021 raising concerns that the patient had heard nothing further after the liver surgery in September 2020. These letters were sent to the East Surrey hospital by the GP. I heard evidence that both consultants hold clinics in two East Surrey hospitals as well as within their own Trust area. Principally the letters were about lack of treatment for a cancer patient and I”
  2. 2. insufficient clarity for patients and staff during inter-provider transfer

    “I remain concerned that there is insufficient clarity for both patients and staff when there is an IPT from SASH to RSFT and vice versa.”
  3. 3. reliance on email instead of automatic electronic systems

    “an ongoing firewall problem between the two Trusts as this places a current reliance on email rather than automatic electronic systems especially given the failure of emails in this case to secure a much-needed appointment”

Responses

  • Built with
  • NVIDIA Nemotron Nano, Super and Ultra
  • Nebius Token Factory inference
  • Qwen3 Embedding 8B on Token Factory
  • Tavily follow-up web search
  • Postgres and pgvector search
  • Next.js site

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