Lillian Robinson

PFD Report Historic (No Identified Response) Ref: 2014-0041
Date of Report 26 January 2014
Coroner Martin Flemimg
Coroner Area Surrey
Response Deadline est. 23 March 2014
Coroner's Concerns (AI summary)
The report text did not detail specific concerns, only indicating that matters giving rise to a risk of future deaths were identified.
View full coroner's concerns
During the course of the inquest the evidence revealed a matter that gave  rise to concern and which, in my opinion, there is a risk that future deaths  could occur by reason thereof unless action is taken.  

The MATTER OF CONCERN is as follows.  –  

RT3848
Sent To
  • Surrey County Council
Response Status
Linked responses 0 of 1
56-Day Deadline 23 Mar 2014
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 22/1/13 I opened an inquest into the death of Lillian Rose Robinson  who, at the date of her death was aged 89 years.  The inquest was  resumed and concluded on 15th and 16th January 2014.  I found that the cause of death to be: ‐  1a.  Bronchopneumonia  I concluded with a Narrative finding
Circumstances of the Death
On 31/10/12, Lillian Rose Robinson was admitted to Brockhurst Care  Home for intermediary care.  On 27/10/12 she was transferred to Upper  Halliford nursing home where she was found to have deteriorated and  she succumbed and died from bronchopneumonia on 28/12/12.
Copies Sent To
I have sent a copy of this report to Chief Coroner Coroners Society for England and Wales
Related Inquiry Recommendations

Public inquiry recommendations addressing similar themes

Communication strategy for patients and families
Scottish Hospitals Inquiry
Coroner family information gaps
Share mortuary reports with coroner service
Fuller Inquiry
Coroner family information gaps
Share Clinical Assessor Advice
Infected Blood Inquiry
Coroner family information gaps
Family Involvement in SAI Investigations
Hyponatraemia Inquiry
Coroner family information gaps
Sharing New Investigation Information
Hyponatraemia Inquiry
Coroner family information gaps
GP Notification of Death Circumstances
Hyponatraemia Inquiry
Coroner family information gaps
Post-Mortem Limitation Authorisation
Hyponatraemia Inquiry
Coroner family information gaps
Post-Mortem Documentation Checklist
Hyponatraemia Inquiry
Coroner family information gaps
Clinician Attendance at Post-Mortem Discussions
Hyponatraemia Inquiry
Coroner family information gaps
Post-Mortem Reporting Standards
Hyponatraemia Inquiry
Coroner family information gaps

Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.