_ (1) There was a failure to give Mr Dixon an appointment 6 months after he was seen in August 2012 (2) There was a failure to give Mr Dixon an urgent appointment for a procedure within 4-6 weeks of the 14/08/2013 (3) Important documentation_was missing_namely the referral form for the procedure that Centre; Burdon Road;, Sunderland, SRZ ZDN Tel 0191 5617843 Fax 0191 5537803 DX 60729 Sunderland wwW.sunderland_ gov.uklcoroner City City Civic took place on 13/01/2014 There appeared to be no systems in place to identify and take action to rectify these problems. Although none of the failures caused or contributed to the death of Mr Dixon and although the Consultant Urological Surgeon had identified some of the problems before Mr Dixons death am concerned that these may impact upon other patients not just within the urology department but in other areas of the hospital work, particularly screening and follow up_ heard evidence about an action plan to deal with (he issues that had arisen particularly about problems with faxes and the proposed electronic improvements_ However it is nearly 6 months since the problems were identified and it may be that a review of the action pian and the timeliness of its implementation would be beneficial together with any other action that could be taken to deal with these concerns so as to prevent future deaths