“There appears to be a significant discrepancy between clinicians on the consenting…”
Dated 21 Jun 2021, from the coroner for Plymouth, Torbay and South Devon. 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 Aug 2021. 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 Jun 2021
- Deadline16 Aug 2021
- Published on judiciary.uk28 Jun 2021
- Today24 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| University Hospitals Plymouth NHS Trust | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 16 Aug 2021. A reply may have been sent and not yet published. |
The coroner’s concerns
– (1) There appears to be a significant discrepancy between clinicians on the consenting procedure for the identical treatment of endoscopy. (2) A ‘sip test’ to exclude aspiration was not performed, and there has been no evidence that this had been noted or remedied at the Trust. (3) A doctor did not take action when viewing an endoscopy report which contained an indication of a possible dangerous complication. (4) Appropriate records were not kept, or were not properly transferred, by senior staff. OFFICIAL
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, 2021-0211
- 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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