“~ (1) Training Records for Nurses”
Dated 5 Feb 2020, from the coroner for West Yorkshire (Eastern). 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 22 Jun 2020, after the 56 days for replies had ended (1 Apr 2020). 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 dated5 Feb 2020
- Deadline1 Apr 2020
- Published on judiciary.uk22 Jun 2020
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Leeds Teaching Hospitals NHS Trust | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 22 Jun 2020, after the 56 days for replies had ended (1 Apr 2020). 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) Training Records for Nurses. The evidence revealed that in 2015, the Trust did not hold records of the training received by individual nurses. Instead, it was left to each individual nurse to maintain their own training records. The concern arising from this is that, without accurate records, a Trust cannot be sure a particular nurse has the required skills and competence to carry out a particular task. Instances of this revealed at the Inquest was whether nurses on ward 40 at LG! had received training in relation to Bair Huggers or BiPAP ventilation equipment used in the care of critically ill children. \ 4 4 I i i i (2) Formal Written Care Plans | The evidence taken at the inquest revealed that despite the complex medical needs of this child, no formal written care plan was created for the period he was in hospital, from | September 2013 to January 2015 (15 months). It was assumed all the clinicians involved would glean sufficient information from a review of his notes. The absence of a plan meant that aspects of his treatment were not exposed as being controversial (and disputed by his parents). An example of this related to hydrocortisone therapy. In complex cases, a comprehensive care plan would provide both parents and clinicians with a basis upon which to obtain a second opinion from an independent source in the event of a dispute, as occurred repeatedly in this case.
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, 2020-0116
- 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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