Isle of Wight NHS Trust admits failings over death reports

The Isle of Wight NHS Trust's chief executive said the trust had not informed her office about Serious Incident (SI) investigations

A NHS trust has admitted "failing terribly" in not disclosing abnormalities over the deaths of patients to the coroner.

Isle of Wight Coroner Caroline Sumeray told a hearing that 20 Serious Incident (SI) investigations were not reported to her by the island's NHS trust before the bodies were cremated.

She said some staff did not understand the nature of the inquest process.

The trust's chief executive Maggie Oldham was fined £500 by the coroner.

'Wanted to weep'

The coroner said she had signed off the death of a 93-year-old woman, before being told of a SI involving the patient's mental health and discharge from hospital.

In another case, the coroner said her "head spun round" when she learned in January that a SI investigation was being carried out into a drug-related death, a month after she had closed the inquest.

She said she "wanted to weep" when she heard that trust staff failed to notify her because "they didn't realise that when there was an inquest, that meant that somebody had died".

"In all 20 cases... I have had to metaphorically resurrect the dead," she said.

"The bodies were released and in every single case they were cremated, which causes me a really big problem now because the trust then subsequently informs me that there are serious incident investigations based on information that wasn't referred to me."

Ms Sumeray said in three cases, deaths were not reported to her by Isle of Wight NHS Trust at all.

She said her death-to-inquest rate was slow because of trust delays.

Ms Oldham told the coroner: "I was extremely disappointed... and I feel terrible... that I'm letting your office down.

"The reassurances that some of the team have given us have obviously been failing terribly."

The trust is currently rated as inadequate and is in special measures.

In a statement released after the hearing, Ms Oldham added: "I apologise to the coroner and to all the families for the recent administrative delays which have been understandably frustrating.

"We are doing everything we can to support the coroner in her duties and minimise the distress for families and loved ones at this saddest of times for them."

The trust said it had since appointed a head of legal services to focus on improving its support to the coroner.