“The hospital Early Warning System used to identify and escalate a deteriorating patient…”
Dated 21 Nov 2018, from the coroner for South Yorkshire East. Sent to 2 organisations or people.
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 8 May 2019, after the 56 days for replies had ended (16 Jan 2019). 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 dated21 Nov 2018
- Deadline16 Jan 2019
- Published on judiciary.uk8 May 2019
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustNamed in the report as “Doncaster Bassetlaw Teaching Hospital” | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 8 May 2019, after the 56 days for replies had ended (16 Jan 2019). These dates can’t tell us whether a reply was due before it went online. |
| Department of Health and Social Care | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 8 May 2019, after the 56 days for replies had ended (16 Jan 2019). These dates can’t tell us whether a reply was due before it went online. |
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 hospital Early Warning System used to identify and escalate a deteriorating patient was not adhered to. This allowed missed opportunities for Mr Burgess’s care to receive Senior Medical reviews which could have altered his management. (2) Inadequate record keeping by clinician within the Clinical notes. There were numerous examples of care having been escalated by nursing staff to doctors but no record of their input following this escalation was entered in the notes, e.g. on 4" December 2017, Mr Burgess’s care was escalated between 11:40 hours and 16:30 hours on at least 5 occasions and no entries were placed in his clinical records. This could have had a detrimental effect on his care and if this practice continues it will potentially affect other patients. (3) Finally, untimed dictated notes of ward rounds, were then entered into the records in a non- chronological order, which was unhelpful and potentially misleading
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, 2018-0364
- 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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