“Inconsistencies in record keeping between specialities”
Dated 22 Aug 2023, from the coroner for Cornwall and the Isles of Scilly. 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 17 Oct 2023.
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 dated22 Aug 2023
- Deadline17 Oct 2023
- Published on judiciary.uk8 Sep 2023
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Royal Cornwall Hospitals NHS TrustNamed in the report as “Royal Cornwall Hospital Trust” | Response publishedPublished on judiciary.uk in September 2023. |
The coroner’s concerns
– (1) Inconsistencies in record keeping between specialities. (2) The process for entering an alert in the digital system that clinical notes have been handwritten in the written notes. (3) The absence of an alert on the EPMA requiring review of the ongoing suspension of prescribed medication.
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, 2023-0312
- 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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