“are, as follows: – (1) Signing and administration of opiate analgesia to a patient…”
Dated 3 Mar 2022, from the coroner for Sunderland. 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 28 Apr 2022. 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 dated3 Mar 2022
- Deadline28 Apr 2022
- Published on judiciary.uk8 Mar 2022
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| County Durham and Darlington NHS Foundation Trust | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 28 Apr 2022. A reply may have been sent and not yet published. |
The coroner’s concerns
are, as follows: – (1) Signing and administration of opiate analgesia to a patient without any evidence of ascertaining why such analgesia was required, and if it was appropriate; (2) Failure by the on-call Registrar to review a patient in the early hours of the morning when called for advice by the FY1 doctor; (3) Failure by a Consultant Physician to follow an established Vascular Pathway despite clearly recognising the correct diagnosis of acute lower limb ischaemia; (4) Poor communication between medical and radiology doctors resulting in: a) delays in CTA being performed; b) inadequate imaging being performed; and c) a complete lack of urgency in reporting the findings of the CTA to the requesting doctors. (5) Very poor standard of care in respect of continuity of care; leaving the vascular referral to Sunderland to a very junior doctor on-call who did not even know the patient; (6) An insufficiently robust review by The Trust of the circumstance leading to the death of Mr Alan Hodgson and of the lessons to be learnt from it, i.e. an insufficient review of the vascular pathway, including its dissemination, awareness and continuous training to improve the importance of the rapid escalation of care against the background of effective communications and handovers between staff to promote holistic patient care.
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, 2022-0067
- 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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