“(brief summary of matters of concern) Regulation 28 – After Inquest Document Template…”
Dated 7 Sep 2022, from the coroner for Lincolnshire. 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 2 Nov 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 dated7 Sep 2022
- Deadline2 Nov 2022
- Published on judiciary.uk5 Oct 2022
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| United Lincolnshire Teaching Hospitals NHS TrustNamed in the report as “United Lincolnshire Hospital” | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
The coroner’s concerns
(brief summary of matters of concern) Regulation 28 – After Inquest Document Template Updated 30/07/2021 With reference to cause of death at 1b. The deceased had liver impairment due to cirrhosis. He was prescribed the anticoagulant Rivaroxaban for presumed deep vein thrombosis. Within 48 hours he developed rectal bleeding. During his admission to hospital his INR was 1.8 indicating blood was thin. Renal function impaired with a GFR of 39 - baseline 46. Rivaroxaban is contradicted in liver impairment, low platelets and severe renal impairment .(Documented in the product literature and British National Formulary). Consequently, it is represented that the deceased should not have been prescribed Rivaroxaban due to the bleeding risk. Administration of Rivaroxaban to someone with impaired clotting and low platelets would exaggerate the anticoagulant effect and be responsible for the rectal bleed and cerebral haemorrhage that resulted. If accepted the potential inappropriate administration may have led to the cause of death and this has important safety implications that are in the public interest. An action plan to prevent future deaths may be needed.
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, 2022-0280
- 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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