“The staffing levels on Ward J83 should be reviewed, notwithstanding that they may…”
Dated 3 Oct 2018, from the coroner for West Yorkshire (Eastern). 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 dated3 Oct 2018
- Deadline28 Nov 2018
- Published on judiciary.uk1 Mar 2019
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Leeds Teaching Hospitals NHS Trust | Response publishedPublished on judiciary.uk in March 2019. |
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 staffing levels on Ward J83 should be reviewed, notwithstanding that they may currently meet the minimum levels prescribed. The ward handles a challenging cohort of patients with liver disease who have complex needs which merit close nursing attention. 2. Evidence taken at the Inquest revealed concerns that treatment plans instituted by clinicians were not always fully or effectively implemented as the staff were often too busy, particularly at night, Example included not hoisting an immobile lady out of bed onto a chair before mealtimes 'and then having time to encourage her to eat. 3._In this case the deceased was frail and losing weight due to not eating. A family member witnessed her food being left on her tray whilst she was laid flat and hence unable to access it with the result that it went cold and she did not eat, despite the concern relating to her nutritional condition. 4. Insufficient time was available for the nursing staff and clinicians to explain treatment decisions to family members. An example given at the Inquest related to a decision to prescribe anti-depressant medication without the family being informed of any psychiatric involvement, 5. Contemporaneous nursing records were not always maintained; for example relating to food and fluid intake (even though nutrition was a matter of concern to the treating clinicians).
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, 2018-0333
- 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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