Coroners' Society of England and Wales

Private and voluntary organisations · Professional membership body

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First report 4 Oct 2013•Latest report 4 Oct 2013

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

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

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from Coroners' Society of England and Wales linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Cornwall

    AI-generated summary

    Jean James · 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

    Jean James was an 85-year-old woman who developed stomach pain on 5 November 2012, was admitted to hospital with suspected appendicitis at approximately 11:00 on 6 November, and was not seen by a doctor until 17:00. She was later diagnosed with a perforated appendix, underwent surgery, and died in hospital on 19 November 2012. The principal concern was that patients admitted via their GP had no defined timeframe for medical review, unlike patients admitted through the Emergency Department, and that records of review times were not kept.

    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. The report was sent to Coroners' Society of England and Wales; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to keep records of doctor review timeframes for GP-referred hospital admissions

    Wider context from the report

    “By contrast, where the patient is admitted to the Medical Admissions Unit or the Surgical Receiving Unit after referral by their GP there is no time threshold within which a doctor should review them. Furthermore, I was told that records in this regard are not kept. On this occasion the question was asked whether, had Mrs James been seen earlier, the outcome may have been different. ████████ felt this was unlikely but he could not exclude the possibility that more prompt treatment by antibiotics may have led to a different outcome. I do not understand the rationale why patients admitted to hospital via their GP should not be seen within the same timeframe as patients admitted via the Emergency Department. I anticipate one justification for this may be that the GP has already conducted some form of medical examination. While that was the case in this instance I can easily see that there may be circumstances where it would not happen. In that situation it cannot be acceptable for a patient to wait more than four hours before being seen and assessed. It is equally the case that patients seen by their GP could actually be more unwell than those who present themselves at the Emergency Department. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Coroners' Society of England and Wales; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a time threshold for doctor review and assessment of GP-referred hospital admissions

    Wider context from the report

    “By contrast, where the patient is admitted to the Medical Admissions Unit or the Surgical Receiving Unit after referral by their GP there is no time threshold within which a doctor should review them. Furthermore, I was told that records in this regard are not kept. On this occasion the question was asked whether, had Mrs James been seen earlier, the outcome may have been different. ████████ felt this was unlikely but he could not exclude the possibility that more prompt treatment by antibiotics may have led to a different outcome. I do not understand the rationale why patients admitted to hospital via their GP should not be seen within the same timeframe as patients admitted via the Emergency Department. I anticipate one justification for this may be that the GP has already conducted some form of medical examination. While that was the case in this instance I can easily see that there may be circumstances where it would not happen. In that situation it cannot be acceptable for a patient to wait more than four hours before being seen and assessed. It is equally the case that patients seen by their GP could actually be more unwell than those who present themselves at the Emergency Department. ”
    Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026