“Concerns were raised during the inquest with regard to communication between teams…”
Dated 29 Oct 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 publishedReplies were due by 24 Dec 2020.
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; a reply may have been sent and not yet published.
- Report dated29 Oct 2020
- Deadline24 Dec 2020
- Published on judiciary.uk8 Dec 2020
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Norfolk and Norwich University Hospitals NHS Foundation TrustNamed in the report as “Norfolk and Norwich University Hospital” | Response publishedPublished on judiciary.uk in December 2020. |
The coroner’s concerns
Concerns were raised during the inquest with regard to communication between teams, particularly to the staff on duty at night as to what information was handed over. Evidence was heard of an easy to use form of communication tool which enables information to be transferred accurately, especially at handover time, between nurses and clinicians, known as SBARD. This helps in reducing the likelihood for errors in communication information. It was not known whether this tool is in use although it was “hoped” it is being used. This is some eighteen months following Miss Gibbs’s death. 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has 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 24 December 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, 2020-0220
- 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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