“Although the Trust had a policy for Restraint for dealing with aggressive patients, it…”
Dated 27 Jan 2015, 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 24 Mar 2015.
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 dated27 Jan 2015
- Deadline24 Mar 2015
- Published on judiciary.uk27 Jan 2015
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| University Hospitals of Leicester NHS TrustNamed in the report as “Leicester University Hospitals NHS Trust” | Response publishedPublished on judiciary.uk in January 2015. |
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) Although the Trust had a policy for Restraint for dealing with aggressive patients, it became clear from the witnesses from the Trust who gave evidence, that many of the staff in the Emergency Department (including the Senior Registrar in charge of the case) were either wholly unaware of the Policy or unaware of, and had no training in, the application of the policy. 1 (2) It also became clear that the Senior Registrar was not familiar with the dangers of prolonged restraint of a patient in the prone (face-down) position (3) When it was decided that the patient was in need of rapid tranquilisation then: a) A supply of Lorazapam from the manufacturer was apparently not available and no policy appeared to have been devised for the priority use of any limited supply of Lorazapam within the Trust and there was no awareness amongst the clinicians of the availability of alternative medications b)The possibility of a licensed product or of the alternative of Promethazine does not appear to have been pursued. The importance of quick-acting drugs, for the purpose of rapid tranquilisation did not appear to have been fully appreciated. (4) Although the NICE guidelines were printed off and consulted in dealing with the rapid tranquilisation, a reference there to the fact that diazepam was “not recommended” was overlooked.
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, 2015-0024
- 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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