“ The results from audits of compliance with safe discharge arrangements using a…”
Dated 13 Mar 2015, from the coroner for Nottinghamshire. 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 8 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 dated13 Mar 2015
- Deadline8 May 2015
- Published on judiciary.uk13 Mar 2015
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustNamed in the report as “Doncaster and Bassetlaw Hospitals NHS Foundation Trust” | Response publishedPublished on judiciary.uk in August 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
– The results from audits of compliance with safe discharge arrangements using a discharge stamp, including the recording of the Early Warning Score on discharge are unsatisfactory 1 6 The improved recording and communication of the EWS from Health Care assistant, to Nurse, to doctor as necessary, is not evident throughout the Hospital The medical staff involved in this Inquest do not agree with the SUI author, that an ECG was indicated during Mr Robinson’s admission. There are no clear guidelines to assist medical staff with this clinical decision making when a patient presents with acute breathlessness. An audit to monitor the threshold for performing an ECG has shown this is still not reliably performed when clinically indicated The risk of there being no one available to provide senior medical review when a registrar is absent remains an ‘extreme risk’ The iHospital which undoubtedly will assist in improving EWS recording, is not yet in place. Implementation is planned for June 2015, and there is potential for delay. Interim plans for a ‘At a glance Board’ are not clear, with confusion as to where the EWS will be recorded.
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, 2015-0225
- 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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