“1, Shropdoc personnel, be that Doctors or Urgent Care Practitioners are not able to…”
Dated 19 Jun 2018, from the coroner for Shropshire, Telford and Wrekin. 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 14 Aug 2018.
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 dated19 Jun 2018
- Deadline14 Aug 2018
- Published on judiciary.uk8 Jul 2018
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| The Shrewsbury and Telford Hospital NHS TrustNamed in the report as “Shrewsbury and Telford Hospital NHS Trust” | Response publishedPublished on judiciary.uk in July 2018. |
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.
— 1, Shropdoc personnel, be that Doctors or Urgent Care Practitioners are not able to access the referring patients GP records. This meant that they did not have the full picture of Patricia’s past medical history before administering any advice or treatment. This is not a one off isolated incident and applies to every case that is referred to Shropdoc. Evidence was given at the inquest from the Shropdoc Urgent Care Practitioners that it would have assisted them. 2. During the evening of the 1°t October 2017, there were only two A&E Doctors on duty (a third had telephoned in sick ). Too few Doctors were therefore on duty in general to cover patient needs and there did not seem to be in place a programme for trying to get a third Doctor to replace the Doctor who had telephoned in sick. 3. | heard evidence that a prescribed drug Ertapenem was not in stock within the A&E department and that led to a delay of some two hours and twenty five minutes until administration. Other suitable alternative drugs were available but not considered. 4, Whilst there was a general awareness of the dangers of sepsis from the Shropdoc and Hospital witness evidence; a. Red flag signs of sepsis were missed. b. Leg bandages were not removed to allow full top to toe examination. c. Sepsis six care bundles were not followed in accordance with guidelines. ACTION SHOULD BE TAKEN ln my opinion action should be taken to prevent future deaths and | 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, 2018-0183
- 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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