“Basic observations repeatedly not being recorded (2) No evidence of on-going senior…”
Dated 10 Feb 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 7 Apr 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 dated10 Feb 2015
- Deadline7 Apr 2015
- Published on judiciary.uk10 Feb 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 “University Hospitals Leicester” | Response publishedPublished on judiciary.uk in February 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
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
— (1) Basic observations repeatedly not being recorded (2) No evidence of on-going senior review on each shift whereby shortfalls in observations would be detected at an early stage (3) Lack of written decision making rational in relation to the frequency of observation (4) No evidence of any reporting system of healthcare professionals that do not practice in accordance with accepted standards and no evidence of support given to those who do report ‘Town Hall Square, Leicester, LE 9BG ‘Tel 0116 4541030 | Fax 0116 225 2537 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. 7 YOUR RESPONSE | You are under a duty to respond to this report within 56 days of the date of this report, namely by 07 April 2015. |, the coroner, may extend the period.
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, 2015-0051
- 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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