“I recognise and acknowledge the actions taken by the Trust with regard to the timeframe…”

The coroner’s concerns

I recognise and acknowledge the actions taken by the Trust with regard to the timeframe and speed with which an unidentified infection may be addressed by antibiotic medication. Notwithstanding the existence of guidance, recommending review at 48-72 hours, and noting that this remains a live discussion topic at the Trust’s training sessions, it was apparent from the evidence heard, that clinicians did not actively consider or appear to follow the guidance, despite blood tests showing continuing signs of infection which broad spectrum antibiotics had not reduced. Nor were microbiology tests ordered early on when antibiotics had had no immediate effect; a missed opportunity confirmed in the evidence heard and which the medical witness suggested could, with hindsight, have been considered. Underlying these events, however, it is apparent that current policies, systems and processes – including electronic records – do not proactively flag, up, drive or require active consideration of tests, including whether and when results have been obtained, or whether further specialist tests should then be required, enabling more timely consideration as to whether targeted antibiotics should be administered, at urgency and pace where a patient remains patently unwell. Accepting that other actions iterated in the Trust’s recent submissions will reduce the risk of similar future deaths, there appear to be no obvious systemic checks and failsafes in patient care as regards infection testing, treatment and then review – especially where treatment is not working. I am acutely aware that where action has been taken, a ‘PFD’ report may be otiose, but in this case my concern persists, notwithstanding the action taken, and nor do I consider that resource grounds significantly preclude further action. I also consider, given the obvious and welcome development of the Electronic Patient Record, that there remains a realistic prospect of some action being taken by which that system flags up, alerts and or far more proactively drives clinical assessment and review, where infection markers persist. I duly consider there remains a risk of further deaths, and that further action should be taken to reduce the risk of death in such circumstances, fully accepting that it is not possible to eliminate that risk entirely. 11. COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: Those members of the family who attended the inquest. I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. 12. SIGNATURE Joseph TURNER Area Coroner for West Sussex, Brighton and Hove

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, 2026-0294

Added to Minute Book

8 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0