Yvonne Sydney Annie Perry

taken: : (1) That the X-ray taken of Mrs. Perry's hip, reported on by the consultant radiologist on the 1glh December 2012, was not acted upon until the 3r January 2013 It was recognised that the Hospital "do not have robust process for tracking that the emergency department consultants have looked at the radiology reports. Without such a system believe further deaths may occur in the future_ Perry .

(2) The GPs who attend the Windsor Intermediate Care Unit do not have access to the electronic hospital notes and records and those witnesses from WICU who attended the inquest considered that such access would improve the care afforded to patients. Similarly without access to the patients notes further deaths may occur in the future_ In my opinion action should be taken to prevent future deaths and believe you have the power to take such action: You are under a duty to respond to this report within 56 of the date of this report; namely by 18th November 2013. I,the coroner, 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. have sent a copy of my report to the Chief Coroner and to the family as properly Interested Persons have also sent it to Care Quality Commission who may find it useful or of interest: am also under a duty to send the Chief Coroner a copy of your response 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 await hearing from you with your response Yours sincerely "Hmft {D Tom Osborne Her Majesty' s Senior Coroner for Milton Keynes This report is being sent to: Family of Mrs Perry Chief Coroner Care Quality Commission days may