“The Immediate Discharge Summary did not include relevant or sufficient information about…”
Dated 9 May 2024, from the coroner for East Riding and Hull. Sent to 6 organisations or people.
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 4 Jul 2024. 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 dated9 May 2024
- Deadline4 Jul 2024
- Published on judiciary.uk14 May 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| St Andrew’s Surgery Hull | 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. |
| Hull University Teaching Hospitals NHS TrustNamed in the report as “Hull University Teaching Hospital” | Response publishedPublished on judiciary.uk in May 2024. |
| NHS England | Response publishedPublished on judiciary.uk in May 2024. |
| Care Quality Commission | Response publishedPublished on judiciary.uk in May 2024. |
| Nursing and Midwifery Council | Response publishedPublished on judiciary.uk in May 2024. |
| City Healthcare Partnership Hull | Response publishedPublished on judiciary.uk in May 2024. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
– (1) The Immediate Discharge Summary did not include relevant or sufficient information about treatment in the community needs or a nursing summary. (2) Despite the presence of a difficult sacral sore which would have benefitted from district nursing care, no referral was made post discharge by the GP surgery. (3) No trigger appears to exist whereby GPs conduct follow up enquiries or visits to patients who have recently been discharged from hospital and who are complaining of a condition which may worsen and failing to attend routine appointments due to a worsening of their condition. (4) An over reliance upon private hygiene care packages with insufficient inquiry into the parameters of care provided by the private domiciliary carers.
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, 2024-0255
- 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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