“have largely been identified and addressed by a Patient Safety Incident Investigation…”
Dated 11 Nov 2025, from the coroner for Cornwall and the Isles of Scilly. 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 6 Jan 2026.
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 dated11 Nov 2025
- Deadline6 Jan 2026
- Published on judiciary.uk14 Nov 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Royal Cornwall Hospitals NHS TrustNamed in the report as “Royal Cornwall Hospital” | Response publishedPublished on judiciary.uk in November 2025. |
The coroner’s concerns
have largely been identified and addressed by a Patient Safety Incident Investigation report that was available to the court. A number of changes and improvements have already been made or will be undertaken, for example, when the Trust’s IT systems are upgraded. One point that did not appear to have been fully resolved, however, centred on the need for patients who are admitted late and unexpectedly (of which the PSII recorded there are over 1,000 annually) to have their usual medication prescribed in timely fashion. On the facts of this case, Tracey was prescribed insulin when the family informed clinical staff she had a diagnosis of diabetes. Her pain relief was not prescribed at the same time, however, and as she became more uncomfortable after the nerve block used intra-operatively wore off, this resulted in her being prescribed opiates (inappropriately) rather than her usual Gabapentin. There was debate at the inquest as to who would be best placed to prepare the prescription and when. Matron thought it could be done by an anaesthetist who would be reviewing the patient preoperatively in any event. (Head of Patient Safety) felt it could be better done by a junior doctor when a patient was admitted and clerked in. On the facts of this case, Tracey was not seen by a junior doctor (other than to have an insulin prescription) and was not formally clerked in. 2 Information Classification: CONTROLLED
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, 2025-0578
- 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
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