“The final version of the patient safety investigation report carried out by the Trust was…”

The coroner’s concerns

– (1) The final version of the patient safety investigation report carried out by the Trust was only received on the first day of the Inquest, some 16 months after the death. The concerns raised in this Inquest have been well known to the Trust for a considerable period of time and the concern is that lessons cannot be learned in a timely fashion if patient safety investigations are so significantly delayed. (2) The patient safety investigation report is not a comprehensive and robust review of the omissions in provision of anti coagulant and does not consider or address the omission to administer anti coagulant because the deceased was transferred between hospitals, nor does it detail all of the incidents of missed anti coagulant, some of which only became apparent upon receipt of the independent expert report. It’s remit and action plan are limited to the community hospital only, and do not consider or address the further instances of omission to administer anti coagulant in the acute hospital setting, where there was a continued failure to carry out a capacity assessment and any subsequent best interests decision making process, failure to escalate these issues, and/or to consider any alternative treatment to reduce the high risk of DVT/PE. (3) Although evidence was heard in relation to the provision of further training in relation to the issues of capacity and best interests decision making, to address the concerns identified in this investigation this was limited to the community hospital setting, when it is known that the issues continued in the acute hospital setting.

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, 2024-0397

Added to Minute Book

8 Oct 2026

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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