“The Court heard evidence that a registered nurse working on the Unit at the me of Mr…”

The coroner’s concerns

– 1. The Court heard evidence that a registered nurse working on the Unit at the me of Mr Crowther’s death was not up to date with Intermediate Life Support (‘ILS’) training, despite this being termed ‘mandatory’. Having heard evidence from the Trust’s Clinical Excellence Lead for Older Peoples’ Services, I am concerned that instances con nue to arise across the Trust whereby clinical staff are undertaking shi s despite not being up to date with the required level of Life Support training. 2. Whilst the Court heard evidence as to relevant changes made to the Trust’s Observa ons Policy since Mr Crowther’s death, I am concerned that despite having an Electronic Pa ent Records system, there is currently no mechanism in use on the wards for contemporaneous digital recording of observa ons. I am concerned that an ongoing risk of future deaths arises from this posi on, in the view of the poten al for such systems to accurately record mings of observa ons, facilitate trend analysis (par cularly in the context of a deteriora ng pa ent), and reduce the poten al for errors, either arising from incorrect / unclear manual recording of observa ons

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, 2025-0500

Added to Minute Book

8 Oct 2026

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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