“2 1”
Dated 6 Feb 2026, from the coroner for Devon, Plymouth and Torbay. 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 3 Apr 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 dated6 Feb 2026
- Deadline3 Apr 2026
- Published on judiciary.uk13 Feb 2026
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Torbay and South Devon NHS Foundation TrustNamed in the report as “Torbay and South Devon NHS Trust” | Response publishedPublished on judiciary.uk in February 2026. |
The coroner’s concerns
– 2 1. There appeared to be a lack of training and understanding by staff at the Trust that it is everybody’s responsibility to report and escalate a serious clinical incident such as this 2. There appears to be no effective process in place for reviewing clinical notes to pick up a clinical issue such as this in circumstances where no complaint has been made by a family member, and no member of staff has recognised or reported it . 3. There appears to be a lack of understanding as to when a Serious Incident Report should be made or actioned retrospectively 4. There appeared to be no process for recording the fact that another organisation such as SWAST had made a Datix referral which would then have mitigated the fact that the SWAST Team failed to pass on their own DATIX to Torbay and South Devon NHS Trust.
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, 2026-0085
- 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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