“Staffing Levels in the Emergency Department of Royal Gwent Hospital During the course of…”
Dated 13 Jul 2021, from the coroner for Gwent. 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 7 Sep 2021.
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 dated13 Jul 2021
- Deadline7 Sep 2021
- Published on judiciary.uk15 Jul 2021
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Aneurin Bevan University Health Board | Response publishedPublished on judiciary.uk in July 2021. |
The coroner’s concerns
1. Staffing Levels in the Emergency Department of Royal Gwent Hospital During the course of the inquest, consideration was given to the the clinical decisions made in the Emergency Department of the Royal Gwent Hospital. I concluded that there was no evidence that Mrs West was displaying signs that would alert the staff to a possible intracranial bleed. However in evidence Dr , Consultant in Emergency Medicine, acknowledged that the staff had not followed hospital protocol or the NICE guidance in relation to the frequency with which observations should be performed. Dr ' assessment of the situation was that this was probably caused by inadequate staff numbers to undertake the full range of duties required. She further stated that this is a frequent and ongoing problem in the Emergency Department. Whilst this did not influence the outcome for Mrs West I am concerned that this may put the lives of future patients at risk.
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, 2021-0239
- 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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