“During his evidence the consultant physician with the responsibility for the care and…”
Dated 15 Sep 2023, from the coroner for Exeter and Greater Devon. 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 10 Nov 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 dated15 Sep 2023
- Deadline10 Nov 2023
- Published on judiciary.uk26 Sep 2023
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Royal Devon University Healthcare NHS Foundation TrustNamed in the report as “Royal Devon University Healthcare Foundation Trust” | Response publishedPublished on judiciary.uk in September 2023. |
The coroner’s concerns
(1) During his evidence the consultant physician with the responsibility for the care and treatment of Mr Brooks acknowledged that the discharge summary was ambiguous and did not make it clear that the 2.5 – 3L was a target fluid intake; he agreed that it could be interpreted that Mr Brooks should be restricted to no more than 2.5 to 3L of fluid a day. As a consequence, the nursing home staff were unaware of the needs of Mr Brooks. The target fluid intake was not met in the period that Mr Brooks was in the nursing home, which contributed to his death.
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, 2023-0351
- 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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