“:- The deceased was on Warfarin but the INR was not checked on 16 April 2013 despite the…”
Dated 2 Apr 2014, from the coroner for Black Country. 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 28 May 2014.
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 dated2 Apr 2014
- Deadline28 May 2014
- Published on judiciary.uk2 Apr 2014
- Today23 Oct 2026
Watch this report
We’ll email you when a response is published on judiciary.uk, or when the 56 days to reply end with none published there yet. Free, and you can stop with one click.
Responses from each recipient
| Sent to | Response |
|---|---|
| The Dudley Group NHS Foundation Trust | Response publishedPublished on judiciary.uk in July 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
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
:- The deceased was on Warfarin but the INR was not checked on 16 April 2013 despite the degree of pain and the history of fall. This Office is open Monday to Thursday 8am to 4pm. Friday 8am to 3pm There was a rise in temperature of nearly 1 degree on the afternoon of 16 April 2013 documented by the IMPACT team which was not reported to the medical staff. This was against a background of paracetamol being administered. It was the evidence off that he would have wanted to know about this and would have wanted the patient reassessed medically prior to the actual discharge from the department. This did not happen, Mr. Dodd having been declared medically fit for discharge prior to the referral to the IMPACT team. There was a considerable delay on the night of the 20 April between the arrival of Mr. Dodd in A&E and his first assessment by_a medically qualified member of staff vis: 20:44 - 00:23. It was the evidence of RE that this was inappropriate, and clearly led to a delay in investigation and diagnosis. 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. vis YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of the report, namely by Wednesday 28th May 2014. 8. COPIES and PUBLICATIONS I have sent a copy of my report to the Chief Coroner and to the following interested Persons : None I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the Coroner, at the time of Ee response, about the release or the publication of your response by the Chief C&roner. - » A. P. Thompson Assistant Coroner BAP
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, 2014-0145
- 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
Ask about this report
AISummaries and questions, with page references. Pro and above.
Sign in to use