“5 (1) The surgical mortality review conducted after Karena's does not seem to have…”
Dated 9 Jan 2024, from the coroner for Cumbria. 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 5 Mar 2024.
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 dated9 Jan 2024
- Deadline5 Mar 2024
- Published on judiciary.uk19 Jan 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| North Cumbria Integrated Care NHS Foundation TrustNamed in the report as “North Cumbria Integrated Care” | Response publishedPublished on judiciary.uk in January 2024. |
The coroner’s concerns
– 5 (1) The surgical mortality review conducted after Karena's does not seem to have considered the role that anticoagulation may have played. I understand trust guidelines suggest it continues until 5-7 days or until the patient regains full mobility. I was told many surgeons will extend this to 28 days. Karena was past the 28 day period but still had significant restriction at the time of discharge. A few years ago I heard a very similar case which occurred at a different health trust. The purpose of this report is to suggest that discharge planning might have a prompt to consider possible ongoing anticoagulant prophylaxis in patients who leave the hospital but have not yet regained full mobility. (2) (3)
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, 2024-0016
- 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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