Recurring concern

Unreliable Medical Examiner processes for reviewing deaths and acting on concerns

Get email alerts

Request correction

First reported 24 Oct 2023•Latest report 2 Dec 2024

Definition

What this concern includes

Includes failures of the dedicated Medical Examiner process for reviewing deaths and following up concerns, including access to relevant clinical records, identification and communication of concerns, tracking of resulting actions, and assurance that concerns are acted upon.

Not included

Excludes general coronial inquest disclosure, autopsy or post-mortem-process deficiencies where the Medical Examiner death-review process is not the identified concern.
Excludes generic governance, records-access or action-tracking failures unless they directly impair Medical Examiner review of deaths or follow-up of Medical Examiner concerns.
Excludes failures in the underlying clinical care or cause-of-death determination unless they are specifically part of the Medical Examiner review and follow-up process.
Excludes clinical records or review processes unrelated to Medical Examiner review of deaths.

Reports: 2
Individual concerns: 2
Date range: 2023–2024
Stated actions: 3

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Betsi Cadwaladr University LHB1

Chelsea and Westminster Hospital1

Chelsea and Westminster Hospital NHS Foundation Trust1

NHS England1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

2 Dec2024
Inner West London
Concerns raised1
1. Lack of Medical Examiner access to obstetric records when reviewing deaths
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Ensure Medical Examiners review all neonatal deaths with access to maternal and obstetric records subject to consent and information-governance requirements.
  Stated by Chelsea and Westminster Hospital NHS Foundation TrustStated completed
Respondent positions 2
1. Position
  Existing statutory Medical Examiner reviews, referral criteria and multidisciplinary reviews are considered sufficient to ensure neonatal deaths are appropriately referred.
  Stated by Chelsea and Westminster Hospital NHS Foundation TrustExisting arrangements considered sufficient
1. Position
  Current access to maternal and obstetric records within information governance processes is considered sufficient for Medical Examiner reviews; no Trust concern remains.
  Stated by Chelsea and Westminster Hospital NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Elton Deutekom · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Elton suffered acute hypoxic-ischaemic injury following a placental abruption during labour and was delivered by forceps at 04:35 on 12 January 2022; despite resuscitation, he was recognised as life extinct at 05:12. The report identifies failures to recognise and respond to abnormal CTG changes, and raises wider concerns about neonatal death referrals, disclosure of evidence, record-keeping, staffing, supervision and CTG monitoring.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of Medical Examiner access to obstetric records when reviewing deaths
Wider context from the report
“7. That in some hospitals the Medical Examiners do not have access to obstetric records when reviewing deaths. ”
Source location
Elton Deutekom · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Ensure Medical Examiners review all neonatal deaths with access to maternal and obstetric records subject to consent and information-governance requirements.

Verbatim wording from the response
“All deaths are now required to be reviewed under statutory duty of the Medical Examiner, therefore all neonatal deaths are reviewed. The Medical Examiners have confirmed that they have full access to maternal/obstetric notes as part of the review process and all access with them when appropriate consent has been obtained with regard to maternal records.”

Source location
Response from Chelsea and Westminster NHS Foundation Trust
Page 3 · response
Published 3 December 2024
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Existing statutory Medical Examiner reviews, referral criteria and multidisciplinary reviews are considered sufficient to ensure neonatal deaths are appropriately referred.

Verbatim wording from the response
“The Trust is confident that it meets its obligations in respect of referring neonatal deaths to the Coroner.”

Source location
Response from Chelsea and Westminster NHS Foundation Trust
Page 3 · response
Published 3 December 2024
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Current access to maternal and obstetric records within information governance processes is considered sufficient for Medical Examiner reviews; no Trust concern remains.

Verbatim wording from the response
“7. That in some hospitals the Medical Examiners do not have access to obstetric records when reviewing deaths.”

Source location
Response from Chelsea and Westminster NHS Foundation Trust
Page 7 · response
Published 3 December 2024
Open published response
24 Oct2023
North West Wales
Concerns raised1
1. Failure to establish awareness and action on Medical Examiner concerns
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Implement a process for reviewing complaints, medical examiner reports, incidents and other matters, and sharing appropriate lessons.
  Stated by Betsi Cadwaladr University LHBStated completed
2. Action
  Triage medical examiner forms, send them to clinical services and upload them to Datix within two weeks, referring potential incident triggers to the Patient Safety Team.
  Stated by Betsi Cadwaladr University LHBStated completed
Respondent positions 2
1. Position
  The Health Board did not receive medical examiner concerns before the inquest because no scrutiny document had been created at the time.
  Stated by Betsi Cadwaladr University LHBDisputes the concern
1. Position
  The independent medical examiner service is provided nationally by NHS Wales Shared Services Partnership, to which the issue was reported.
  Stated by Betsi Cadwaladr University LHBRedirects responsibility
AI-generated summary

Jennifer Lydia Campbell · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Jennifer Lydia Campbell, aged 73, died on 24 February 2022 after an ERCP referral for obstructing gallstones was not received by the endoscopy department. She became severely unwell and died from infection and pneumonia associated with the obstructing gallstones. The principal concerns were the absence of an investigation into the lost referral, lack of learning or audit to prevent recurrence, and continued reliance on paper-based referrals.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to establish awareness and action on Medical Examiner concerns
Wider context from the report
“d. Matters relating to the ERCP which did not take place were identified by the Medical Examiners in their report dated 4 days after the deceased’s death. There was no evidence as to whether the Health Board had been made aware of the concerns therein and if so, what action they had undertaken as a result. ”
Source location
Jennifer Lydia Campbell · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement a process for reviewing complaints, medical examiner reports, incidents and other matters, and sharing appropriate lessons.

Verbatim wording from the response
“We do however accept that we have improvements to be made to our own process, and the West Integrated Health Community have developed and implemented a process in November 2023 to ensure that any complaints, medical examiner reports, incidents and other matters are adequately reviewed to ensure we are able to provide patients and families the best response and outcome, and to ensure lessons learnt are appropriate and shared.”

Source location
Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 1 November 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Triage medical examiner forms, send them to clinical services and upload them to Datix within two weeks, referring potential incident triggers to the Patient Safety Team.

Verbatim wording from the response
“At an organisational level, our Mortality Review Team have developed and introduced a process whereby medical examiner forms are triaged upon receipt and will be sent to our clinical services and uploaded to our Datix quality management system within 2 weeks, ensuring they are available for access by those undertaking investigations. Following this triage, the team will also send a copy to the Patient Safety Team if anything is identified which may need to trigger the incident process. This provides a further safety net and was introduced over the summer of 2023 as a result of your earlier concerns.”

Source location
Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 1 November 2023
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The Health Board did not receive medical examiner concerns before the inquest because no scrutiny document had been created at the time.

Verbatim wording from the response
“In relation to a lack of action on concerns from the medical examiner, whilst I acknowledge your own concerns, the Health Board only received the report from the medical examiner on the day of the inquest as a result of your inquiries (and I understand you are aware of this issue at the inquest). The Senior Medical Examiner Officer for North”

Source location
Response from Betsi Cadwaladr University Health Board
Page 1 · response
Published 1 November 2023
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The independent medical examiner service is provided nationally by NHS Wales Shared Services Partnership, to which the issue was reported.

Verbatim wording from the response
“Wales has confirmed no scrutiny document was created at the time of the death by them, and therefore the Health Board was not in receipt of the concerns they had. The medical examiner service is independent to the Health Board and provided nationally by NHS Wales Shared Services Partnership. We have reported this issue to them.”

Source location
Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 1 November 2023
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of Medical Examiner access to obstetric records when reviewing deaths

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Failure to establish awareness and action on Medical Examiner concerns

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Actions described in response 1

Respondent positions 2

Actions described in response 2

Respondent positions 2