Thomas Mallinson
30 Jun 2025 · Coroner Nicholas Shaw · Cumbria
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. lack of face to face assessment for elderly patient with comorbidities
“I wish to thank [REDACTED] for his attendance and and assistance at the hearing. It was acknowledged that on 18th the advice”
2. delayed escalation of urgent referral
“[the deceased]'s case was sent electronically to the service, marked for 2 hour attention”
3. lack of continuity alert for repeated calls
“there was no alert to a call handler to indicate recent contacts for the same patient with the same condition”
4. systemic neglect of vulnerable patient
“In my summing up after hearing the evidence in this case I explained the legal concept of neglect as a failure to provide basic care and (in this case) medical attention for someone in a dependent condition who can not provide it for himself”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“Given the above I am concerned that future deaths may occur if urgent requests are not dealt with more promptly”
This report
“[the deceased]'s case was sent electronically to the service, marked for 2 hour attention”