Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of standard operating procedures for worsening patients in renal unit
The earlier warning
Jason Clemens · 2 Jul 2025 · Guy Davies, Cornwall & the Isles of Scilly
“There were no applicable standard operating procedures for worsening patients in the renal unit at the date of [the deceased]'s death and none had been implemented by the date of Inquest.”
judiciary.uk/…/jason-clemens-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Jason Clemens (2 Jul 2025) · stated timescale: none stated
“Standard Operating Procedure (SOP): This (SOP) is now completed and has been uploaded onto the Trust's intranet page for all staff to have access to. A copy of the SOP is attached to the response as 'Enclosure”
judiciary.uk/…/2025-0336-Response-from-Royal-Cornwall-Hospitals…
What recurred
- 9 Feb 2026 · Janet Tripp · Guy Davies · Closely related · confidence 0.85 (high)
The clearest link, quoted from both reports:
Earlier · Jason Clemens · 2 Jul 2025
“There were no applicable standard operating procedures for worsening patients in the renal unit at the date of [the deceased]'s death and none had been implemented by the date of Inquest.”
Later · Janet Tripp · 9 Feb 2026
“There was insufficient evidence before the court to indicate that the above failings found at Inquest had been addressed by the hospital.”
What happened next
No web check of the stated actions has been published for this chain.