“The revised training and flow chart does not include any reference to staff ina community…”
Dated 23 Apr 2015, from the coroner for County Durham and Darlington. 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 18 Jun 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 dated23 Apr 2015
- Deadline18 Jun 2015
- Published on judiciary.uk23 Apr 2015
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| County Durham and Darlington NHS Foundation TrustNamed in the report as “County Durham and Darlington NHS Trust” | Response publishedPublished on judiciary.uk in April 2015. |
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The coroner’s concerns
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— (1) The revised training and flow chart does not include any reference to staff ina community hospital being able to obtain emergency advice from an expert in the ‘emergency department of one of the Trust's acute hospitals (or from an expert in another department of the said hospitals if appropriate) to assist in giving immediate ‘medical cover whilst, for example, other steps are being taken or whilst an ambulance is on route after having been summoned. It may well be the case that in urgent situations immediate medical advice from an appropriate expert might be beneficial when trying to ensure a patient's safety and this is not included in the revised Trust policies. This is something that should be given consideration to. ‘ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisation have the power to take such action,
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, 2015-0159
- 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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