More than 100 warning letters were sent by coroners to government and health bodies in 2023, highlighting staff shortages, lack of NHS resources and long wait times, a report has found.
The figures were based on the amount of prevention of future death reports (PFDs) which are sent by coroners to NHS Trusts and health bodies when a coroner thinks action is needed to protect lives.
According to the BBC, 109 identified last year were linked to NHS pressures, making it the highest figure in the past six years.
Coroners are judges in charge of inquests, who investigate the circumstances of deaths that appear to have an unnatural, unknown or violent cause of death.
In some cases, these deaths may have been caused by medical negligence due to the patient not receiving the required treatment or failure to diagnose a disease.
This was the case when Ten-year-old William Gray died in May 2021 after his second severe asthma attack in seven months.
The tragedy occurred in October 2020, when William was struggling to breathe in the middle of the night. His mother gave him CPR and he was rushed to Southend Hospital by ambulance but was discharged four hours later.
In the following months, his family tried and failed to get the specialist help they needed.
Some changes were made to William’s inhaler but, after a consultant appointment, he was “lost to follow-up” at the hospital, his inquest heard. His GP did not prescribe continuing preventative medication to control his condition.
The inquest also heard the incident was recorded as a “severe asthma attack” rather than a respiratory attack.
After William’s inquest in December 2023, the coroner wrote a PFD report to Health Secretary Victoria Atkins and the NHS bodies responsible for his care.
The children’s asthma service “remains under-resourced”, William’s death was “avoidable”, and better treatment “would and should” have saved his life, the coroner added.
According to reports, about 35,000 inquests take place in England and Wales each year. Out of those, the coroner writes around 450 PFD, or Regulation 28, reports.
The BBC analysed 2,600 PFDs – and supporting documentation – sent between 2018 and 2023.
The proportion of the total number of PFD reports that referenced an NHS resource issue rose to one in five in 2023, from one in nine in the two years before COVID-19.
Of the 540 reports written last year, 109 were found that highlighted a long wait for NHS treatment, a shortage of medical staff or a lack of NHS resources such as beds or scanners.
Of these, 26 involved mental illness or suicide, and 31 involved ambulances and emergency services.
Further reading
Medical misdiagnosis or delay – Oakwood Solicitors
WHAT TO DO NEXT
Get in touch today for a no-obligation consultation. Choose one of the methods on the right-hand side of this page, or call us on 0113 200 9720 to find out how we can help you.
Jade Glover is a Solicitor in the Medical Negligence team. She has worked for the company for over 9 years and completed her training during that time. She has specialised in Personal Injury clai…
Medical Negligence Team – Case Studies Showcase
Here is a collection of recent case studies from our Medical Negligence department, showcasing not only the variety of matters they help to resolve, but also the figure awarded to the client upon …
View
