During course of the inquest the evidence revealed matters giving rise to concern: In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to _ 1_ The inquest heard that there was no clear system for escalation Iprioritisation by treating clinicians in relation to management of the OGD Iists and patient need where the OGD team said there was no capacity; The inquest heard that it had been identified in Accident and Emergency that the OGD was required. The notes were marked accordingly but there was no clear system to ensure that this was followed up prior to the ward round on AMU the next day;
3. When a decision was made to depart from the recognised best practice timescales the rationale was not recorded and there was no system to ensure that a suitably experienced clinician agreed with the decision; ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 10 February 2020. !, the coroner; may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION sent a copy of my renort itouthe Chief Coroner and to the following Interested Persons namelyl behalf of the family, who may find it useful or of interest am also under a duty to send the Chief Coroner a copy of your response May May " the you. have

The Chief Coroner may publish either or both in a complete or redacted or summary form; He may send a copy of this report to any person who he believes may find it useful or of interest You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. Alison Mutch OBE HM Senior Coroner 16.12.2019 Mku