“On 20 February 2025, a week before the deceased's death, the frequency of care rounds was…”
Dated 7 Aug 2025, from the coroner for County Durham and Darlington. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 2 Oct 2025.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated7 Aug 2025
- Deadline2 Oct 2025
- Published on judiciary.uk13 Aug 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| County Durham and Darlington NHS Foundation TrustNamed in the report as “County Durham & Darlington NHS Foundation Trust” | Response publishedPublished on judiciary.uk in August 2025. |
The coroner’s concerns
On 20 February 2025, a week before the deceased's death, the frequency of care rounds was reduced, in error, from hourly to four-hourly. The member of staff responsible for the error is unaware of how the error occurred. That being the case, there is a concern that the error could occur again and could cause or contribute to a future death.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2025-0418
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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