“They are : 1”
Dated 11 Mar 2019, from the coroner for Plymouth, Torbay and South Devon. 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 9 Jun 2019, after the 56 days for replies had ended (6 May 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 dated11 Mar 2019
- Deadline6 May 2019
- Published on judiciary.uk9 Jun 2019
- Today27 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| University Hospitals Plymouth NHS Trust | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 9 Jun 2019, after the 56 days for replies had ended (6 May 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) They are : 1. Mr. Bradfield was not given his steroids on 2.12.13 2. Mr. Bradfield was not prescribed intravenous hydrocortisone on 4" and 5" December 2013 when Mr. Bradfield had reported vomiting 3. Mr. Bradfield was not put on a stress dose of steroids whilst in Derriford hospital 4. The awareness and training of staff on the issue of steroid management. 5. The lack of a policy on the administration of steroids generally and their use in situations where a number of co — morbidities are present despite this death having arisen in 2013. 6. The training and awareness of staff on the meaning of “ Nil by Mouth “ in patients who are suffering from a number of co —morbidities and are on important prescribed medication which needs to be taken regularly notwithstanding any planned necessary procedures .
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, 2019-0086
- 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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