“~ (1) The Trust Policy and Protocol for Resuscitation states at Appendix 3 that the call…”
Dated 28 Oct 2016, from the coroner for Derby and Derbyshire. 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 23 Dec 2016. 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 dated28 Oct 2016
- Deadline23 Dec 2016
- Published on judiciary.uk28 Oct 2016
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| University Hospitals of Derby and Burton NHS Foundation TrustNamed in the report as “Derby Teaching Hospitals NHS Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 23 Dec 2016. 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.
~ (1) The Trust Policy and Protocol for Resuscitation states at Appendix 3 that the call out criteria for the Adult Resucitation Team is : All Gardiac Arrests All Respiratory arrests Any Unresponsive patient or visitor with Heart rate > 150 Heart rate < 40 Respiratory rate >40 Respiratory rate < 8 Systolic BP < 80 mmHg Oxygen Saturations < 90% Had these criteria been applied to Mrs Turner then the resuscitation team would not have been called, despite clinicians who gave evidence to the court that she was critically ill. The court heard evidence that person’s suffering an intracerebral event or head injury can be critically if and in need of resuscitation but have initial normal vital signs parameters. it may be that in the policy and protocol the parameters for critically ill unresponsive patients are too broad and as a consequence a proportion of critically ill patients will be denied the best possible chance of being treated by a skilled resuscitation team. (2) The method by which Mrs Turner was conveyed to the CT Scanner and back to the ward was described by the ITU consultant, who gave evidence, as ‘dangerous.’ He stated that at the very least Mrs Turner should have been escorted by an anaesthetist and ODA, with appropriate vital signs monitoring and resuscitation equipment and drugs to deal with any medical emergency en route and equipment and drugs to protect and manage her airway.
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, 2016-0386
- 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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