“The doctor who originally prescribed the Clexane did not do so in accordance with…”
Dated 16 Aug 2016, from the coroner for Plymouth, Torbay and South Devon. 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 11 Oct 2016.
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 dated16 Aug 2016
- Deadline11 Oct 2016
- Published on judiciary.uk16 Aug 2016
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| University Hospitals Plymouth NHS TrustNamed in the report as “Plymouth Hospitals NHS Trust” | Response publishedPublished on judiciary.uk in August 2016. |
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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.
— (1) The doctor who originally prescribed the Clexane did not do so in accordance with Derriford Protocol; (2) The doctor's prescription error was not identified during Pharmacy reviews intended to pick 1 Derriford Park, Derriford Business Park, Plymouth, PL6 5QZ Tel 01752 204636 | Fax up precisely this sort of shortcoming; (3) |! was advised that during Mr Glibbery’s admission he lost_a substantial amount of weight estimated at between 6 — 10 kilograms. (who gave evidence) expressed their difficulties in having patients weighed. This is particularly difficult for patients who have undergone hip replacements where, | was told, a hoist that is available is not high enough to return patients back to their beds. The importance of this is obvious in patients whose medication is weight-dependent. It is believed that Mr Glibbery was on the cusp of requiring a downward review of the amount of Clexane prescribed to him.
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
- 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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