“S are as follows: That no-one checked whether Mrs Russell could read, her admission pack…”
Dated 4 Aug 2020, from the coroner for Norfolk. 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 dated4 Aug 2020
- Deadline29 Sep 2020
- Published on judiciary.uk16 Oct 2020
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| James Paget University Hospitals NHS Foundation TrustNamed in the report as “James Paget University Hospital” | Response publishedPublished on judiciary.uk in June 2022. |
The coroner’s concerns
S are as follows: That no-one checked whether Mrs Russell could read, her admission pack has a long section on communication but not once is the question asked can you read/write or something of that nature. Mrs Russell would have been given menus to select from and been expected to read other things whilst in hospital, but nobody checked that she could do this. On discharge no one checked that could read and understand the discharge summary. The inquest was 8 months after Mrs Russells’ death and when I asked the nurse who discharged her about his current practice around patients being asked about literacy his reply was “I’m thinking about it” so even a death had not altered his practice. The hospital has not introduced anything during this long period of time to ascertain if their patients can read/write. I appreciate that it can be embarrassing to ask the staff and patient, but it is vital that if people are being discharged home with written instructions, they can read them to check those instructions, or be shown in a different way what the instructions are, eg. a diagram, getting a relative to read them or a carer. I find it surprising that nothing has been done on the hospital’s own initiative in 8 months and I remain concerned that a similar incident may occur again.
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, 2020-0149
- 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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