“The evidence revealed that the Medical Registrar did not check the JAC medicines database…”
Dated 1 Aug 2018, from the coroner for Isle of Wight. 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
Report put online after its 56 daysOrganisations 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.
judiciary.uk put this report online on 30 Oct 2018, after the 56 days for replies had ended (26 Sep 2018). These dates can’t tell us whether a reply was due before it went online. A reply may have been sent and not yet published.
- Report dated1 Aug 2018
- Deadline26 Sep 2018
- Published on judiciary.uk30 Oct 2018
- Today23 Oct 2026
Watch this report
We’ll email you when a response is published on judiciary.uk, or when the 56 days to reply end with none published there yet. Free, and you can stop with one click.
Responses from each recipient
| Sent to | Response |
|---|---|
| Isle of Wight NHS Trust | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 30 Oct 2018, after the 56 days for replies had ended (26 Sep 2018). These dates can’t tell us whether a reply was due before it went online. |
The coroner’s concerns
– 1. The evidence revealed that the Medical Registrar did not check the JAC medicines database to see that Mr Hingert had already been administered a stat dose of antiplatelets and anticoagulant medication before prescribing second dose of these medications. 2. The Medical Registrar prescribed aspirin to continue at 300mg rather than at the standard dose of 75mg daily. 3. Mr Hingert had already been prescribed continuing doses of Fondaparinux and Ticagrelor, which (fortuitously) were not administered. 4. There was evidence that at least one of the clinicians treating Mr Hingert had not been trained to use the JAC medicines database. 5. There was a 2-hour delay in writing up a verbal order with regard to a prescribing decision. 6. A decision was made to treat Mr Hingert, who was already confused, with the hypnotic Zopiclone, which may not have been a sound clinical decision. 7. Upon discovering the errors with the medications which are documented above, a nurse did not follow hospital protocol and make a DATIX incident report 2 despite acknowledging that she should have done so immediately.
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, 2018-0280
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
Something wrong, such as a date or who it was sent to? Report a mistake
Is this report about someone close to you? You can ask us to remove names from our pages.
Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
Ask about this report
AISummaries and questions, with page references. Pro and above.
Sign in to use