“Coroner's Court and Office, Doneaster Crown Court, College Road, Doncaster, DNI 3HS”
Dated 1 Jun 2015, from the coroner for South Yorkshire East. 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
Deadline passedReplies were due by 27 Jul 2015. A reply may have been sent and not yet published.
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.
- Report dated1 Jun 2015
- Deadline27 Jul 2015
- Published on judiciary.uk1 Jun 2015
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Rotherham Doncaster and South Humber NHS Foundation Trust | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 27 Jul 2015. A reply may have been sent and not yet published. |
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.
— Coroner's Court and Office, Doneaster Crown Court, College Road, Doncaster, DNI 3HS. ‘Tel 01302 320844 | Fax 01302 364833 (1) The systems described as being in place which should be followed to ensure effective communication between families/carers appear not to be routinely followed. As this ‘communication is an integral part of a patient's management and future treatment plans it is essential that all staff are aware of the need for this communication, the nature of it and who has. primary responsibility for ensuring that it takes place. Furthermore, there is no evidence of any effective auditing process to ensure such systems are being followed. (2) The early discharge plan was described as a mechanism to try and ensure a seamless transition from inpatient care to community based care in appropriate cases. Whilst this is. clearly a system adopted locally and currently being re-evaluated, given it's significance i facilitating smooth transitions at a time which was recognised as being difficult for many patients returning to the community, consideration should be given as to whether the current guidance etc adequately incorporates the ethos and workings of the early discharge plan. Witnesses knowledge and understanding of this pathway was variable. Coroner's Court and Office, Doncaster Crowa Court, College Road, Doncaster, DNI 3HS ‘Tel 01302 320844 | Fax 01302 364833, ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you The Chief Executive and Medical Director 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, 2015-0209
- 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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