Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Darren Goddard · 9 Mar 2020 · Sarah-Jane Richards, South Wales Central
“(3) Premature discharge post-operatively from the recovery unit with the missed opportunity to recognise the adverse effect of sepsis when they occurred.”
judiciary.uk/prevention-of-future-death-reports/darren-goddard
What was promised
Stated action 1 · response to Darren Goddard (9 Mar 2020) · stated timescale: 11 March 2020
“Review and provide definite warnings (oral and written) of sepsis when consenting patients to TRUS, and upon their discharge.”
judiciary.uk/…/2020-0060-Response-from-Dr-Hopkins-Redacted.pdf
Stated action 2 · response to Darren Goddard (9 Mar 2020) · stated timescale: none stated
“We can confirm that a single leaflet, which is produced by the British Association of Urological Surgeons (BAUS), is now used, which states that patients should expect to go home on the same day, with no specific time scales given.”
judiciary.uk/…/2020-0060-Response-from-Dr-Hopkins-Redacted.pdf
Stated action 3 · response to Darren Goddard (9 Mar 2020) · stated timescale: ongoing (held on hold due to COVID-19)
“Further training of Triage nursing staff and doctors of the sepsis 6 bundle and =e} Score (NEWS) documentation, escalation and the implementation of the Sepsis 6 bundle.”
judiciary.uk/…/2020-0060-Response-from-Dr-Hopkins-Redacted.pdf
2 further stated actions are listed on the full chain page.
What recurred
- 6 Mar 2025 · Annette Lewis · Kerrie Burge · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Darren Goddard · 9 Mar 2020
“(3) Premature discharge post-operatively from the recovery unit with the missed opportunity to recognise the adverse effect of sepsis when they occurred.”
Later · Annette Lewis · 6 Mar 2025
“[the deceased] should have been referred for surgical review rather than being discharged.”
What happened next
No web check of the stated actions has been published for this chain.