“There was within Mr Richardson’s records an ambulance crew report which recorded that Mr…”
Dated 24 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 19 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 dated24 Mar 2015
- Deadline19 May 2015
- Published on judiciary.uk24 Mar 2015
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| James Paget University Hospitals NHS Foundation TrustNamed in the report as “James Paget University Hospital NHS Foundation Trust” | Response publishedPublished on judiciary.uk in March 2015. |
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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.
— There was within Mr Richardson’s records an ambulance crew report which recorded that Mr Richardson was said to have not eaten for 5 days. In evidence before me it was confirmed that the ambulance report would have been available to the person who undertook the MUST screen. [t also appeared that this may not have been reviewed at the time. If it had been reviewed the evidence given before me was to the effect that the information might have led to a MUST score of 2 which would in turn have led to a referral to dietician services. Although the expert evidence was that Mr Richardson's nutrition did not play a material part in his death, | am nevertheless concerned that in different circumstances a failure to follow up information or review the ambulance record and/or any other records with which a patient is admitted and $0 miss the information could affect the outcome for the patient and that there is therefore a risk of future deaths. .
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, 2015-0114
- 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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