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recurance

Tyler Ryan

17 Oct 2023 · Coroner Carly Henley · Newcastle upon Tyne and North Tyneside

The coroner's concerns

  1. 1. delayed detection of need for genetic testing

    “The delay in Paediatric Pathology Reports results in the delayed detection of the need for genetic testing amongst surviving siblings of children who die of Sudden Death in Childhood. Currently, it is not until the Pathologist provides a report that the need for genetic testing is identified. Reports can take up to two years to be filed.”
  2. 2. lack of molecular autopsy use

    “[REDACTED] and [REDACTED] gave evidence that more widespread use of molecular autopsy would assist in detecting genetic abnormalities in children who have died suddenly, leading to greater opportunities to prevent future deaths within their families and in other families.”
  3. 3. underutilization of molecular autopsy

    “[REDACTED], Consultant [name redacted] gave evidence that [the deceased] is, to date, the only human in history to have been found to have these two RYR2 variants which is significant to his family and to the wider scientific community. Greater use of molecular autopsy would save lives within families and in other families. The detection of these variants is directly relevant to others and the prevention of future deaths.”
  4. 4. outdated SUDIC/Kennedy Protocol

    “[REDACTED] gave evidence that the development of the use of molecular autopsy calls for a revision of the SUDIC Protocol also known as the Kennedy Protocol.”

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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