“On Paul's transfer from The Royal Cornwall Hospital to Liskeard Community Hospital on 18…”
Dated 27 Jun 2024, from the coroner for Cornwall and the Isles of Scilly. Sent to 2 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 22 Aug 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 dated27 Jun 2024
- Deadline22 Aug 2024
- Published on judiciary.uk28 Jun 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Cornwall Partnership NHS Foundation Trust | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 22 Aug 2024. A reply may have been sent and not yet published. |
| Royal Cornwall Hospitals NHS Trust | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 22 Aug 2024. A reply may have been sent and not yet published. |
The coroner’s concerns
On Paul's transfer from The Royal Cornwall Hospital to Liskeard Community Hospital on 18 April 2022 5 (1) There was no clear, detailed and direct handover between doctors of the two hospitals (2) A treatment plan including the need to continue to treat Paul for dehydration and what to do in the event of deterioration was not agreed and recorded clearly between clinical staff of both hospitals (3) Any handover which did take place was not properly recorded in Paul's medical notes (4) An error in the writing out of a prescription for intravenous fluids at the Royal Cornwall meant that the administration of hydrating fluids at Liskeard Community Hospital was delayed.
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, 2024-0344
- 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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