“Handover of Information”
Dated 9 Jun 2014, from the coroner for Plymouth, Torbay and South Devon. 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 4 Aug 2014. 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 dated9 Jun 2014
- Deadline4 Aug 2014
- Published on judiciary.uk9 Jul 2014
- Today27 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| University Hospitals Plymouth NHS TrustNamed in the report as “Plymouth Hospitals NHS Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 4 Aug 2014. A reply may have been sent and not yet published. |
The coroner’s concerns
1. Handover of Information. The need for Mrs Daws to undergo a chest Xray and for the result to be checked appears to have been lost as medical staff have changed at the end/start of consecutive shifts. You may wish to consider whether there needs to be a formal handover in respect of every patient where outstanding investigations are highlighted. 2. A chest X-ray should have been ordered at the time of Mrs Daws admission into the emergency department. One was ordered approximately four hours later but it was not performed for nearly 17 hours. This was described as “inexplicable” during the Inquest hearing. It is plainly undesirable for an investigation that is considered urgent to be delayed for so long without anyone identifying the issue. Related to this issue is that once the X-ray was performed, the result was not seen by medical staff for over 24 hours. No satisfactory explanation was put forward as to why this occurred.
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, 2014-0318
- Added to Minute Book
- 8 Oct 2026
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- 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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