“Evidence emerged during the inquest that there was a failure to contact a Doctor and it…”
Dated 24 Jan 2018, from the coroner for Black Country. 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 publishedOrganisations 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 dated24 Jan 2018
- Deadline21 Mar 2018
- Published on judiciary.uk8 Jun 2018
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| The Dudley Group NHS Foundation TrustNamed in the report as “The Dudley Group NHS Trust” | Response publishedPublished on judiciary.uk in June 2018. |
The coroner’s concerns
– 1. Evidence emerged during the inquest that there was a failure to contact a Doctor and it isn’t clear if this was a system failure through the “nerve centre” system designed to inform the on call Doctor. 2. There were two separate incidents of vomiting and poor record keeping of when these occurred. 3. There was poor communication to the family about the initial fall.
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, 2018-0030
- 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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