Stephen Barton
PFD Report
Historic (No Identified Response)
Ref: 2021-0326
Coroner's Concerns (AI summary)
The NHS lacks a system for tracking non-cancer outpatient appointments, unlike cancer cases. Implementing such a system could prevent unnecessary deaths and improve administrative efficiency.
View full coroner's concerns
The MATTER OF CONCERN is as follows: Stephen missed numerous out-patient appointments. I heard expert evidence from a 1 Staffordshire Place, Stafford, ST16 2LP Telephone: 01785 276126 or 276127 Email: sscor@staffordshire.gov.uk hospital consultant indicating that in the great majority of cases there is no way of tracking out-patient appointments in the NHS. This is however done in cancer cases. The consultant felt it should not be too difficult to develop a system of tracking out-patient appointments in non-cancer cases. If realistically this could be introduced it might well save a lot of administrative time and indeed prevent unnecessary deaths.
Sent To
- Department of Health and Social Care
Response Status
Linked responses
0 of 1
56-Day Deadline
26 Nov 2021
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 6 August 2019 I commenced an investigation into the death of Stephen Thomas BARTON . The investigation concluded at the end of the inquest. The conclusion of the inquest was 'Natural causes following a lack of proper primary health care intervention and insufficient access to secondary health care' with the cause of Stephen's death being 1a Sepsis 1b Chronic otitis media with cholesteatoma in the right ear'. CIRCUMSTANCES OF THE DEATH: Stephen was a serving prisoner found dead in his cell at HMP Dovegate on 27 July 2019. Death resulting from an ear condition.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.