“It was accepted by the Trust that the deceased had been provided and discharged with…”
Dated 12 Aug 2025, from the coroner for Birmingham and Solihull. 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 7 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 dated12 Aug 2025
- Deadline7 Oct 2025
- Published on judiciary.uk14 Aug 2025
- Today21 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| University Hospitals Birmingham NHS Foundation TrustNamed in the report as “UNIVERSITY HOSPITALS BIRMINGHAM NHS FOUNDATION TRUST” | Response publishedPublished on judiciary.uk in August 2025. |
The coroner’s concerns
– 1. It was accepted by the Trust that the deceased had been provided and discharged with medication (gabapentin) that did not belong to him and had missed two doses of antibiotics (fidaxomin) due to the drug being out of stock, which had not been communicated to or escalated to treating clinicians. 2. In evidence the Trust were unable to confirm whether the issues set out in 1. above sat solely with the nursing team or also involved pharmacy. 3. Whilst evidence was given in relation to the discharge nurse having undertaken reflection and a focus group being set up to explore improvements with discharge and planning there was no evidence as to how the wrong medication was provided to the deceased and whether this was a discharge only issue or also an issue with allocation and distribution of medication by pharmacy or by ward staff. 4. There was no evidence to explain how the deceased missed two doses of antibiotics due to the drug being out of stock, why treating clinicians were not informed or why an alternative antibiotic was not administered in its place. The Trust were unable to talk to what, if any, systems were in place to ensure that patients were not left without necessary medication. 5. I am concerned that there may still be a risk to life of patients within the trust if they are provided with the wrong medication or miss necessary doses of prescribed medication.
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, 2025-0423
- Added to Minute Book
- 8 Oct 2026
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- 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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