Muluembet Yohanes

I am Melanie Sarah Lee, Assistant Coroner, for the coroner area of Inner North London.

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

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. I have a duty to send a copy of your response to the Chief Coroner. In accordance with the Chief Coroner’s Publication Policy, you should send me  any representations regarding publication of your response. These  representations should be made at the same time as the response is provided. I will pass any representations received to the Chief Coroner for a decision. Please note any links to webpages included in the response will not be checked  for sensitive information prior to publication, as the information is already online . The names of those who do not respond to PFD reports are regularly published on the Chief Coroner’s webpages Non-responses to Prevention of Future Death (PFD) reports – Courts and Tribunals Judiciary.

SUMMARY OF CORONER’S CONCERN There is no suitable 111 Pathways disposition for pituitary surgery and no prompt for call handlers to ask about hospital discharge advice. See section 9.