“The standard NEWS documentation contains a list of scores on the left, and corresponding…”
Dated 22 Jun 2018, from the coroner for Avon. 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 17 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 dated22 Jun 2018
- Deadline17 Aug 2018
- Published on judiciary.uk9 Jul 2018
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Bristol NHS Foundation TrustNamed in the report as “University Hospitals Bristol 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) The standard NEWS documentation contains a list of scores on the left, and corresponding clinical responses in a column on the right. My understanding of the system was that when the relevant score was reached, the corresponding clinical response was mandatory. The impression | gained from listening to the majority of the nursing staff was that there was an element of discretion / clinical judgment to be applied in determining whether the clinical responses that were ‘required’ when the relevant score was reached were actually necessary. The more senior nursing staff were clear that the relevant responses were mandatory, but that was not the impression given by the more junior staff. This evidence (which gave the impression that staff discretion could be applied to the clinical responses) was given after the staff had, apparently, been given additional NEWS training following Mr Fox’s death. (2) 1 did not have the benefit of any expert evidence about the process of “re-triggering” patients under NEWS, and | am therefore unable to comment on whether it is clinically appropriate. | did hear evidence that the practice was commonplace within the hospital. Telephone 01275 461920 Email AvonCoronersTeam @bristol.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL ACTION SHOULD BE TAKEN In 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, 2018-0192
- 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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