“failure of the medical staff to recognise the significance of the potassium results (2)…”
Dated 11 Sep 2013, from the coroner for Coventry. 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
Report put online after its 56 daysOrganisations 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.
judiciary.uk put this report online on 26 Jan 2014, after the 56 days for replies had ended (6 Nov 2013). These dates can’t tell us whether a reply was due before it went online. A reply may have been sent and not yet published.
- Report dated11 Sep 2013
- Deadline6 Nov 2013
- Published on judiciary.uk26 Jan 2014
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| University Hospitals Coventry and Warwickshire NHS TrustNamed in the report as “University Hospital Coventry and Warwickshire” | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 26 Jan 2014, after the 56 days for replies had ended (6 Nov 2013). These dates can’t tell us whether a reply was due before it went online. |
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
— (1) failure of the medical staff to recognise the significance of the potassium results (2) failure of the laboratory to inform the Ward staff of the abnormal potassium results 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you as Chief Executive of the Trust have the power to take such action. ¢ | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 6" October 2013. |, the coroner, may extend the period.
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, 2013-0228
- 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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