“Following Naeem’s death the Trust, University Hospital Dorset NHS Foundation Trust (UHD)…”

The coroner’s concerns

Following Naeem’s death the Trust, University Hospital Dorset NHS Foundation Trust (UHD) instructed an independent review of the circumstances of his death and the processes in place within the Trust. This led to the Trust taking action to amend their practice around disposal of drugs and working patterns of doctors at the Trust. I am concerned that the practices in place at the time of Naeem’s death at Poole Hospital, which have now been changed, will be operating in other Trusts nationally. Evidence at the Inquest revealed that at the time of Naeem’s death a process in place at Poole Hospital that if there were small volumes of medicines to be disposed of by representatives of the Trust which were less than 50ml in volume, such as after surgery had taken place, these would be squirted into the sharps bins and then the needles would also be disposed of in the sharps bin too. This was identified in the independent review which concluded that this practice posed a risk that fatal medicines could be accessed from the sharps bin. As a result, UHD now use gels in the sharps bins which immediately denature and destroy the liquids squirted into the sharps bins. I am concerned that what was happening at the time of Naeem’s death continues to happen at other Trusts across England and Wales and could lead to future deaths. The review and the coronial investigation also revealed that Naeem died whilst working the 9th shift in a run of 11 night shifts for UHD which began on 12th June 2025 and that in June 2025 he undertook clinical work for more than one provider on the same calendar day on different occasions, and on one occasion he undertook daytime work for an external provider before commencing a resident overnight shift for the Trust later the same day. The review also identified that trust systems for job planning, rostering, appraisal, and secondary employment operated independently and were not designed to provide an integrated view of timing, sequencing, or cumulative workload across employers, whether over short periods or across an annual cycle. Whilst UHD have undertaken work to resolve this issue, I am concerned that this practice exists at other Trusts in England and Wales and could lead to fatigue and fatal outcomes to patients and doctors. w 10. 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: 1. Naeem’s family 2. University Hospital Dorset NHS Foundation Trust 3. General Medical Council 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. SIGNATURE

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, 2026-0319

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