Barbara Cope

NHS
The Rotherham
NHS Foundation Trust

Rotherham Hospital
Moorgate Road
Oakwood
Rotherham
S60 2UD

www.therotherhamft.nhs.uk

4 August 2026

Mrs S L Slater

Area Coroner

South Yorkshire (East District)
Coroner's Court and Office
Crown Court

College Road

Doncaster

DN1 3HS

Dear Mrs Slater

Inquest Touching the Death Barbara Joan Cope:  Regulation 28 Preventing Future
Deaths Report

I write further to your letter dated 8 June 2026.

I understand that following review of the evidence heard at the Inquest dealing with the
circumstances of Barbara Joan Cope's death, a number of matters were raised that were of
sufficient concern to invoke your statutory duty under Paragraph 7, Schedule 5, of the

Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations)
Regulations 2013.

I was disappointed to hear that the evidence heard at the Inquest did not provide you with

the level of assurance you required in relation to the timely review and escalation of
abnormal blood results. As an organisation we take your concerns seriously and are
committed to ensuring that the learning arising from this matter is fully considered and

acted upon.

For ease of reference I have addressed each of the concerns set out in your report in the
order in which they are presented.  My response is intended to provide clear assurance
regarding actions taken, further work underway, and the governance arrangements in place

to oversee delivery and sustained improvement.

Chief Executive, The Rotherham NHS Foundation Trust

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 1. 

Although the blood sample was collected and tested in a timely manner, there
was no evidence of communication and/or follow up of the abnormal result,

therefore time critical medication was not commenced until 19 hours later.

Over the years, the Trust has undertaken a programme of quality improvement work, led by

the Deputy Medical Director and Chief Clinical Information Officer to strengthen our
responsiveness to abnormal results.  This has included ensuring that all abnormal results

are flagged within MEDITECH (our electronic patient record).  In addition, a Standard

Operating Procedure setting out the required actions for managing investigation results was

introduced and communicated Trust wide.

Since Mrs Cope’s death we have reviewed and updated the Standard Operating Procedure

for the Management of Critically Abnormal Pathology Results in Clinical Areas and I attach

a copy of the same for your reference.

The aforementioned Standard Operating Procedure aims to standardise the actions

required across the Trust when a critically abnormal pathology result has been identified
and subsequently transmitted to the clinical area.  The result must be escalated

immediately to the appropriate member of staff to enable any treatment/management to be

implemented in a timely manner.  The results must be documented in the patient’s medical

and nursing records and the effect of any actions to correct the results noted.

Section 5 of the Standard Operating Procedure sets out the process laboratory medicine
staff are required to follow when an abnormal result has been noted which provides an
electronic trail of the date, time and details of the escalation.  Laboratory Medicine staff are
expected to use the situation, background, assessment, recommendation (SBAR)

communication tool to communicate results which fall outside of laboratory critical limits.

Once the results have been communicated to the clinical area, laboratory staff will ask the
receiver to repeat key information to ensure understanding, take their full name and
designation and record the details of the results transmission in the Laboratory Information

Management System (LIMS).  This is in accordance with the Pathology Policy for the
Transmission of Results by Telephone (QPL-PQ-004).

If the result has been given to a Registered Nurse, the laboratory staff will inform them that

they need to escalate the information to a clinician within 30 minutes.  The Registered
Nurse must document the name of the clinician they have informed and if no action has
been taken within 60 minutes, the Registered Nurse must escalate to the Senior Nurse on

Duty.

In the event laboratory staff are unable to contact the clinical area, Section 5.2 of the
Standard Operating Procedure sets out a clear escalation process of contacting the
Specialist Registrar in the first instance, secondly the Consultant and finally the Clinical Site

Management Team.

Chief Executive, The Rotherham NHS Foundation Trust

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 An  audit has been conducted by Pathology to check that the documentation for time critical

results telephoned to clinical areas complies with the  Standard Operating Procedure with a

finding that results audited had  been communicated in a timely manner. An additional audit

of 50 results is currently underway focusing on whether time critical results have been

documented and acted on appropriately. The  result of this audit is expected by the end of

August 2026.

In addition, the Trust has developed a Power Bl  module to monitor acknowledgement of

results which continues to show  an improvement in clinicians’ responsiveness to the

management of test results.

2. 

Even when the patient clinically deteriorated overnight and required two

separate clinical reviews, the blood results were not reviewed and/or acted
upon.  If clinical records and recent investigation results are not reviewed

then appropriate medical management will be delayed or will not occur.

I was concerned to hear that Mrs Cope  deteriorated overnight, requiring two separate

clinical reviews and despite this, her blood results were not  reviewed.  The Trust has  a

clear handover process in place whereby medical staff working in hours, handover tasks

for follow up to the  out of hours team  at the face-to-face handover meetings.  In addition to

this, we will imminently launch a pilot within our Urgent and Emergency Care Centre of the

use  of the ‘alertive bleep’ system which flags critical blood results on the bleep system.

3. 

This patient was transferred from the emergency department to the care of
Surgery.  A referral was then made for Gastroenterology input, they then

requested a blood test for paracetamol levels.  This was not followed up for
17 hours.  There needs to be clear communication, understanding and record
keeping of who is responsible for the patient and the ongoing follow up and

care in these circumstances.

Mrs Cope  was  admitted under a surgical Consultant, remained on the surgical ward and

therefore under the care of the surgical team  who were responsible for her  care.

The  Deputy Chief Nurse in conjunction with colleagues from the learning from deaths

programme, clinical effectiveness team  and the quality governance team will include the

learning from this  incident in the Quality Newsletter focusing on the importance of acting

upon time  critical blood results.

In relation to your concern that  staff do not  have a clear understanding of who is

responsible for the  ongoing care and follow up of patients, our electronic patient record

clearly states the name of the  admitting Consultant and any tasks relating to that particular

Chief Executive, The Rotherham NHS Foundation Trust

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 patient will be under that admitting Consultant until such time that the care is transferred to
a different Consultant and this is amended on the system.

I hope the above provides you with the assurance that the Trust has taken your concerns

seriously and please do not hesitate to contact me in the event I can be of further

assistance to you at this time.

Yours sincerely

Chief Executive

Chief Executive, The Rotherham NHS Foundation Trust

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