“The family complained they were unable to get staff on Karenza ward to listen to them”
Dated 21 Oct 2020, from the coroner for Cornwall and the Isles of Scilly. 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
Deadline passedReplies were due by 16 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 dated21 Oct 2020
- Deadline16 Dec 2020
- Published on judiciary.uk8 Dec 2020
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Royal Cornwall Hospitals NHS TrustNamed in the report as “Royal Cornwall Hospital” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 16 Dec 2020. A reply may have been sent and not yet published. |
The coroner’s concerns
i) The family complained they were unable to get staff on Karenza ward to listen to them. It was accepted in evidence that, at the time, there were staffing 1 Information Classification: CONTROLLED difficulties on the ward that have since been addressed. A lack of cleanliness with Mr Woodhouse being left in soiled bedding and clothes. It was not possible at inquest to come to a view that this was the cause of the infections in the knee and/or elbow. iii) Potential delay in the administration of antibiotics. In evidence, Dr accepted that with the benefit of hindsight this was the case. While it was not causative of the death it was possible this had resulted in an avoidable wash-out in theatre; iv) Delays or omissions of prescribed Parkinson’s medication. Matron had reviewed the nursing records. She accepted in evidence that there were ‘multiple’ occasions when medication was given late and three occasions when it was not given at all. She conceded nursing standards had fallen below what could reasonably be expected. The inquest was told this is a national problem coming out of the difficulties caused where a patient needs time-specific medication that falls outside traditional ward times for the administration of medication. I was also informed that a business case has been prepared for consideration by the Board for the appointment of a specialist Parkinson’s nurse and pharmacist. It was not known whether the case had been accepted and, if so, when it will be taken forward. ii)
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, 2020-0217
- 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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