“Mr Watt arrived at A&E at 8pm, he was seen within an hour by a nurse practitioner and…”
Dated 3 Jun 2020, from the coroner for Cumbria. 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
All responses publishedOrganisations 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.
- Report dated3 Jun 2020
- Deadline29 Jul 2020
- Published on judiciary.uk26 Aug 2020
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| North Cumbria Integrated Care NHS Foundation TrustNamed in the report as “North Cumbria Integrated Care Trust” | Response publishedPublished on judiciary.uk in June 2022. |
The coroner’s concerns
– (1) Mr Watt arrived at A&E at 8pm, he was seen within an hour by a nurse practitioner and admission arranged. However after he got onto the ward at 2am he did not see a doctor to be clerked in until 10.30. Both Allan’s family and I as coroner felt this delay was unacceptable. (2)After Allan had been clerked in and IV fluid and antibiotic advised he did not receive an IV line or a first dose of antibiotic until 3pm –it was now 19 hours after he had arrived in A&E and in that period he had received no fluid or drug treatment. (3)Allan died at 18.45, evidence suggested that he may have been too ill to survive even at the time he arrived in the A&E department but I have no doubt that the want of timely assessment and treatment denied him any chance at all. It is my hope that attention to these concerns will indeed prevent future deaths at your hospital.
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, 2020-0127
- 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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