“Evidence emerged during the inquest 1”
Dated 14 Oct 2020, from the coroner for Derby and Derbyshire. 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 9 Dec 2020. 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 dated14 Oct 2020
- Deadline9 Dec 2020
- Published on judiciary.uk3 Dec 2020
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| University Hospitals of Derby and Burton NHS Foundation TrustNamed in the report as “University Hospital of Derby and Burton” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 9 Dec 2020. A reply may have been sent and not yet published. |
| NHS England | Response publishedPublished on judiciary.uk in June 2022. |
The coroner’s concerns
Evidence emerged during the inquest 1. That patient electronic and paper based transfer information is not kept on one database. Mr Coweys’ handover notes were kept on extra Med, his neurological observations on Patient Track and the falls form on his hard copy notes; 2. Trust local policy regarding treatment for head injures is not consistent with NICE Guidelines and doctors cannot be expected to be aware of all trust local policies; 3. Anticoagulation guideless do not cover a situation where anticoagulation is being given as a preventative measure as opposed to a treatment; and 4. The Trusts local falls form does not direct doctors to the relevant guidance regarding head injuries simply asks if a CT head scans indicated
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, 2020-0205
- 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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