“The Clinical Advisor missed critical ‘red flags’ thereby failing to recognise the…”
Dated 3 Sep 2015, from the coroner for Avon. 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
Deadline passedReplies were due by 29 Oct 2015. 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 dated3 Sep 2015
- Deadline29 Oct 2015
- Published on judiciary.uk3 Sep 2015
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Care Quality CommissionNamed in the report as “CQC” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 29 Oct 2015. A reply may have been sent and not yet published. |
| South Western Ambulance Service NHS Foundation TrustNamed in the report as “South Western Ambulance Service” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 29 Oct 2015. A reply may have been sent and not yet published. |
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 Clinical Advisor missed critical ‘red flags’ thereby failing to recognise the seriousness of the deceased’s condition (3) The Clinical Advisor gave inappropriate advice thereby failing to safeguard against the risk deterioration and ensure the safety of the deceased. (4) There was failure to make sufficient and timely welfare calls when a response could not be provided. (5) The Trust should review the training and mentoring of all existing Clinical Advisors with a clear and structured programme to regularly assess and re-assess the competencies of the Clinical Advisors. (6) The Trust should ensure there is proper training, assessment, mentoring and support provided for all newly appointed Clinical Assessors. (7) The Trust is failing to meet it’s own target of auditing every month 3% of the calls of Clinical Advisors. In some months no audits at all have been performed. (8) In failing to carry such audits the Trust has identified that there are real concerns that there is no safety net in place to identify potential risks or training needs. (9) The Trust should take immediate steps to ensure the necessary resources are allocated to achieve at feast the level of audit the Trust itself has determined necessary. (10) The Trust should have in place a structured response to actioning any deficiencies identified in such audits whether that be for individual Clinical Assessors or as a professional group inciuding trend analysis.
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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- 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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