“itis clear that much work has been done by the Adult Critical Care team to learn from the…”
Dated 24 Oct 2013, from the coroner for Nottinghamshire. 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
Deadline passedReplies were due by 19 Dec 2013. A reply may have been sent and not yet published.
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.
- Report dated24 Oct 2013
- Deadline19 Dec 2013
- Published on judiciary.uk18 Dec 2013
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Nottingham University Hospitals NHS Trust | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 19 Dec 2013. A reply may have been sent and not yet published. |
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) itis clear that much work has been done by the Adult Critical Care team to learn from the mistakes made in this case. It is now not possibie to obtain 500 m! bags of 5% dextrose fluid without the input of a pharmacist, and they are not stored in the same place as 500m! bags of normal saline. | also heard about further training, and that sharing of these events has taken place. (2) The evidence suggested that Omnicell cabinets may be available soon in E12 at the QMC. it was however clear that, although Critical Care at the City campus has Omnicell cabinets in place, this is not the case across the trust, nor even all all critical care areas in the trust. While a mistake in the context of intensive care and arterial lines may be more serious for some patients, there could be equaily catastrophic outcomes for patients in non critical care settings, if there remains a risk of different types of fluids being mixed up. (3) Whilst mindful of the cost implications involved, | am concerned about the risk of future deaths occurring in other parts of the trust which may not have as robust a safety standard as Critical Care (certainly at the City Hospital campus) now appears to have. (4) lt is not for me to make specific recommendations regarding the purchase of specified equipment, but a trust-wide review of policies for safe storage of different types of fluids would reduce the risk of a similar tragedy occurring in future. This would include issues such as where these fluids are stored, how they are packaged and labelled, who is entitled to change bags, what checks are in place, and how this is recorded.
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, 2013-0274
- Added to Minute Book
- 8 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
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