“The majority of medical care, including the identification and assessment of…”
Dated 17 Oct 2022, from the coroner for Nottingham City and 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 12 Dec 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 dated17 Oct 2022
- Deadline12 Dec 2022
- Published on judiciary.uk20 Oct 2022
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Nottingham University Hospitals NHS TrustNamed in the report as “Nottingham University Hospital NHS Trust” | Response publishedPublished on judiciary.uk in October 2022. |
The coroner’s concerns
(1) The majority of medical care, including the identification and assessment of deteriorating patients, was done by inexperienced junior doctors with no easy access to input from more experienced doctors; and (2) There was an established culture and practice of most blood tests results not being reviewed in a timely manner. Other areas of concern existed regarding other issues but plans were in place to address these areas and so I did not have ongoing concerns of a risk of future deaths.
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, 2022-0324
- 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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