“Unclear dose/type of sedation medication given, possible excess dose given, poor…”
Dated 19 Jan 2022, from the coroner for Nottinghamshire. 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 16 Mar 2022.
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 dated19 Jan 2022
- Deadline16 Mar 2022
- Published on judiciary.uk24 Jan 2022
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Nottinghamshire Healthcare NHS Foundation Trust | Response publishedPublished on judiciary.uk in January 2022. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
– 1. Unclear dose/type of sedation medication given, possible excess dose given, poor documentation 2. Delayed recognition of Mrs Whitehead’s declining condition 3. No medical clerking from admission until her collapse 4. No Consultant involvement after admission 5. Inability to reach Duty Doctor for deteriorating patient 6. Delay in calling paramedics 7. Delay in Paramedics gaining access to the ward Many of these issues have been the subject of scrutiny in at least two previous Inquests, that have followed deaths on inpatient wards of the Trust. I have received reassurance during these Hearings that the issues have been addressed, but this case illustrates that they clearly remain. The issues are very serious in my view.
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, 2022-0016
- 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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