“Community Nurse administered the anticoagulant on the 26th August 2012 without seeking…”
Dated 5 Sep 2013, from the coroner for Leicester City and South Leicestershire. 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
All responses publishedReplies were due by 31 Oct 2013.
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; a reply may have been sent and not yet published.
- Report dated5 Sep 2013
- Deadline31 Oct 2013
- Published on judiciary.uk5 Sep 2013
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Leicestershire Partnership NHS Trust | Response publishedPublished on judiciary.uk in May 2014. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
– (1) Community Nurse administered the anticoagulant on the 26th August 2012 without seeking medical advice from a Doctor even though she knew Mrs Vaghadia had been bleeding from the site of the previous injection. Although the expert evidence in this case is that the nurse’s actions did not cause or contribute to the death in this instance, there is a risk that such action in another case may not have the same outcome and could be causative of death. (2) Although the nurse had full knowledge of the bleeding she did not share this with other health care professionals when she spoke to them. If she had there was a real possibility that Mrs Vaghadia would have been admitted sooner. In this instance, the expert opined that on a balance of probabilities had Mrs Vaghadia been admitted sooner the outcome was unlikely to have been different. Nevertheless, full and appropriate information sharing is paramount and the nurse’s actions fell short of her professional duties and could have caused an adverse outcome. (3) Nurse appeared to have no professional insight into her actions and that they could cause or contribute to death. (4) Although not causing or contributing to Mrs Vaghadia’s death, it is clear that Nurse actions were not appropriate. I have a concern that Nurse lacks training and/or experience as well as insight that her actions and therefore her practice may continue and cause future deaths
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, 2013-0201
- 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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