Source · Prevention of Future Deaths
Paul Hardy
Ref: 2015-0041
Date: 4 Feb 2015
Coroner: Stephanie Haskey
Area: Nottinghamshire
Responses identified: 0 / 1
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Healthcare staff failed to follow instructions for obtaining blood/urine samples for cancer investigation, neglected recommendations for INR monitoring, and did not conduct a Significant Event Analysis.
Date
4 Feb 2015
56-day deadline
1 Apr 2015 est.
Responses identified
0 of 1
Coroner's concerns
Healthcare staff failed to follow instructions for obtaining blood/urine samples for cancer investigation, neglected recommendations for INR monitoring, and did not conduct a Significant Event Analysis.
View full coroner's concerns
That there was a clear failure by Healthcare Staff to act upon instruction given by a visiting Advanced Nurse Practitioner to obtain and process blood and urine samples for the investigation of possible urological cancer There was a failure to act upon a clear recommendation made by the Prison and Probation Ombudsman's Clinical Reviewer for facilitating the effective obtaining of blood samples for INR monitoring There was a failure to act upon a clear recommendation made by the Clinical Reviewer that there should be a Significant Event Analysis of the events surrounding_the death of Paul Hardy:
Report sections
Circumstances of the death
Paul Hardy was a serving prisoner at HMP Lowdham Grange, operated by Serco, when he was confirmed by his local hospital as suffering from urological cancer. Whilst this was not; in the end, the immediate cause of his death, there were delays and errors in process whilst he was under the care of Lowdham Grange which caused unnecessary suffering and distress_
Action should be taken
In my opinion action should be taken to prevent future deaths and believe your organisation has the power to take such action my
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Report details
- Reference
- 2015-0041
- Date of report
- 4 February 2015
- Coroner
- Stephanie Haskey
- Coroner area
- Nottinghamshire
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 1 Apr 2015 (estimated).
Sent to
- Nottinghamshire Healthcare NHS Trust