“| heard in evidence from Mr Young, the Trust's Clinical Director who had carried Out a…”
Dated 1 Nov 2018, 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
Deadline passedReplies were due by 27 Dec 2018. A reply may have been sent and not yet published.
Organisations 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.
- Report dated1 Nov 2018
- Deadline27 Dec 2018
- Published on judiciary.uk1 Nov 2018
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| University Hospitals Coventry and Warwickshire NHS Trust | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
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) | heard in evidence from Mr Young, the Trust's Clinical Director who had carried Out a Root Cause Analysis, | heard also from one of the Trust's consultant neurosurgeons. Both consultants expressed their belief that neurosurgical patients of this nature required additional support from their consultant physician colleagues. | was told that this has been an issue for some time and remained unresolved. In particular, there was concern that a junior neurosurgical doctor was left to implement an alcohol withdrawal regimen. | was. told that these difficulties are mot confined to patients who are admitted with alcohol-related issues but extend across the whole range of neurosurgical patients who require medical input. (2) | was told that the aloohol withdrawal protocol was difficult to understand. This resulted in the doctor prescribing diazepam when Lorazepam should have been ued, | was told and shown an action plan that the Trust intends to implement to Improve [he process. (3) |*
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
- 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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