“S are as follows: Whilst there has been a detailed Serious Incident review of the…”
Dated 25 Sep 2020, from the coroner for Nottingham City and Nottinghamshire. 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 30 Nov 2020, after the 56 days for replies had ended (20 Nov 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 dated25 Sep 2020
- Deadline20 Nov 2020
- Published on judiciary.uk30 Nov 2020
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Sherwood Forest Hospitals NHS Foundation 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. |
The coroner’s concerns
S are as follows: Whilst there has been a detailed Serious Incident review of the circumstances of Mrs Day’s death conducted by the Trust, it remains unclear as to how and why these prescription errors occurred. It is my view that a similar prescription error could occur again, as there remains a number of different charts and documents that allow for muddled prescribing of, or omission of, anticoagulants, when there are complex medical conditions and concern re likely bleeding. Whilst the development of an electronic prescribing system may increase the probability of more clarity in prescription of anticoagulants, this is not in place currently. In addition, this alone in my view will not ensure oversight of anticoagulant management, unless other measures are taken to ensure senior review of patients, and a clear prescription plan recorded for all staff to follow. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 20 November 2020. I, the coroner, may extend the period.
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, 2020-0199
- Added to Minute Book
- 8 Oct 2026
- Reuse
- 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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