“Diary systems for ensuring referrals to different specialisms were not effective, such as…”
Dated 11 Jul 2017, from the coroner for Leicester City and South Leicestershire. 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 5 Sep 2017. 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 dated11 Jul 2017
- Deadline5 Sep 2017
- Published on judiciary.uk11 Jul 2017
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Leicestershire Partnership NHS TrustNamed in the report as “Leicestershire NHS Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 5 Sep 2017. A reply may have been sent and not yet published. |
The coroner’s concerns
— (1) Diary systems for ensuring referrals to different specialisms were not effective, such as for physiotherapy and the failure of these systems was not identified until the inquest was held. Furthermore, the system for entering and updating/amending incident reporting was unclear and reported incidents were not reviewed by a senior employee in a timely fashion on this occasion. (2) Communication with family members was inadequate and inaccurate, the "named nurse" system was ineffective and therefore opportunities were lost to share information and to keep the family informed and involved. The failure of the Trust to engage with family members of patients with mental health issues have been raised in the past as a concern, and contrary to NICE Guidelines. (3) Mrs Astill had two unwitnessed falls during her time in the unit, both were recorded on CCTV and both were due to interaction with other patients. The first fall was quickly attended by numerous nursing staff members, but there was a considerable delay in actually physically attending to the patient, examining her or taking basic observations. In a professional nursing environment this delay in first ,aid provision was of concern and the Trust should consider enhanced training to ensure immediate effective interventions I. ACTION SHOULD BE TAKEN I n my opinion action should be taken to prevent future deaths and I believe you 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, 2017-0440
- 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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