“The author of your Trust's After Action Review report gave evidence that when the…”

The coroner’s concerns

The author of your Trust's After Action Review report gave evidence that when the deceased was admitted to the Alexandra Hospital, Redditch on 17.9.25 and treated for a likely recurrence of a kidney infection: (a) charts monitoring his intake and output of fluids should have been started and maintained, but were not. Nurses should do this as a matter of course for any patient with a urinary or kidney infection, and the doctors who reviewed him regularly during his 5 day admission should also have picked up on the fact that his fluids were not being monitored. It is unclear why no fluid charts were started, or why this failure was not spotted; (b) a venous thromboembolism ( VTE ) assessment was carried out, which identified that the deceased had an identified risk of suffering a VTE event and prescribed compression stockings to mitigate that risk. Both the nurses and doctors looking after the deceased should have picked up on this, but did not, with the result that the deceased was without VTE prophylaxis for the duration of his admission. Whilst it may not have been easy ( at the time ) for doctors and nurses to find the VTE assessment in the deceased's notes, it is concerning that, if it was being looked for and not found, the search was not being followed through. Both (a) and (b) above suggest that some doctors and nurses do not appreciate the fundamental importance of the issues identified. 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 the deceased’s next of kin. 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 David REID HM Senior Coroner for Worcestershire

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, 2026-0403

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14 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