“At the time of Zakariyya's attendance at the Doncaster Royal Infirmary on the 11th July…”
Dated 7 Oct 2014, from the coroner for South Yorkshire East. 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 2 Dec 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 dated7 Oct 2014
- Deadline2 Dec 2014
- Published on judiciary.uk7 Oct 2014
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustNamed in the report as “Doncaster and Bassetlaw NHS Foundation Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 2 Dec 2014. 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.
— At the time of Zakariyya's attendance at the Doncaster Royal Infirmary on the 11th July 2013, there were significant deficiencies in both the matters recorded in the notes and the extent of the examination and assessment undertaken. These can be summarised as follows: 1. Failure to document an assessment of Glasgow Coma Score and the result. 2. Failure to document the location of the haematoma as well as its size. 3. Failure to follow Trust procedures in undertaking and documenting complete observations (blood pressure, heart rate, respiratory rate, temperature, saturations, capillary refill). Ultimately, | concluded that these matters did not affect the outcome in Zakariyya's case but did fee! that should these practices continue, future patients may well be at risk. Counsel for the family suggested to the Consultant in Emergency Medicine that the computerised systems described during evidence could be enhanced to ensure that clinicians could not move onto the next step until these vital observations had been undertaken and documented. The Consultant responded very positively to this suggestion. In essence therefore my concern is that failure to carry out full and complete assessments and observations in babies and children attending the Accident and Emergency department and then to document to same will put future patients at risk until these matters are properly addressed.
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, 2014-0440
- 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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