“The staff grade A&E doctor who treated Mrs Holmes on 1 February did not consider what…”
Dated 2 Jul 2015, from the coroner for Central and South East Kent. 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 27 Aug 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 dated2 Jul 2015
- Deadline27 Aug 2015
- Published on judiciary.uk2 Jul 2015
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| East Kent Hospitals University NHS Foundation TrustNamed in the report as “East Kent Hospitals University NHS Trust” | Response publishedPublished on judiciary.uk in July 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
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
The staff grade A&E doctor who treated Mrs Holmes on 1 February did not consider what action was necessary given the history of trauma and multiple fractured ribs on x-ray and that she was at risk of internal bleeding since she was receiving anticoagulation therapy. ACTION SHOULD BE TAKEN A protocol should be drawn up for the A&E Department to provide for the consideration of reversal of anticoagulation therapy in all cases where a patient has sustained trauma and is in receipt of this type of medication.
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, 2015-0254
- Added to Minute Book
- 8 Oct 2026
- Reuse
- 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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