“During the inquest the clinician giving evidence indicated that the discharge paperwork…”
Dated 16 May 2019, from the coroner for Worcestershire. 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 28 Jul 2019, after the 56 days for replies had ended (11 Jul 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 dated16 May 2019
- Deadline11 Jul 2019
- Published on judiciary.uk28 Jul 2019
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Worcestershire Acute Hospitals NHS TrustNamed in the report as “Worcestershire Acute Hospital NHS Trust” | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 28 Jul 2019, after the 56 days for replies had ended (11 Jul 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) During the inquest the clinician giving evidence indicated that the discharge paperwork from the clinical decision-making unit is different to that from other wards/departments and it is not clear what a follow-up or advice/guidance is given to patients. E The family of the deceased contend that there was no advice or follow-up and that the deceased was left not knowing what to do about his increasing pain. It appears that no documentation has been found within the hospital about this The standardisation of discharge documentation would appear to be in need of review and | invite you to consider this. (2) (3) ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation 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, 2019-0156
- 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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