“- Specific leaflets relating to the procedure and aftercare were not handed to the patient”
Dated 12 Mar 2015, from the coroner for Norfolk. 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 May 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 dated12 Mar 2015
- Deadline7 May 2015
- Published on judiciary.uk12 Mar 2015
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Norfolk and Norwich University Hospitals NHS Foundation TrustNamed in the report as “Norfolk and Norwich University Hospital NHS Foundation Trust” | Response publishedPublished on judiciary.uk in March 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
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— - (1)- Specific leaflets relating to the procedure and aftercare were not handed to the patient. It is understood a “tick box” has now been added to documentation recording | that this is done. This will only work if forms are properly and timely completed — see below. It is understood training and auditing of forms is now in place, but it is not clear how this is being carried out. (2) The Thromboprophylaxis Risk Assessment form was not completed at any point throughout Mrs Tweedy’s dealings with the hospital. Had the Risk Assessment been completed this would have flagged up specific risk factors relating to Mrs Tweedy well before the operation. It was noted the Risk Assessment had not been completed following Mrs Tweedy being anaesthetised and this did start discussion between the Consultant Surgeon overseeing the procedure and the Anaesthetist about the risk factors and action to be taken. However, at this stage in the procedure, it did not allow for a full and proper consideration of the relevant information early on when- proper thought could: have been given to the risks and potential risks. (3) Nursing notes on discharge did not fully cover all the factors required to be checked before a patient is discharged. (4) There was no evidence that the Nurse completing the notes had actually seen Mrs Tweedy prior to discharge. (5) The checklist Form for completion on discharge was not completed.
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, 2015-0095
- 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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