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recurance

Ethel Reed

8 Feb 2024 · Coroner Sally Robinson · East Riding and Hull

The coroner's concerns

  1. 1. peripatetic staffing regime on temporary ward

    “H130 is on the 13th floor of Hull Royal Infirmary. It has an East and a West wing and spans the full floor. It was opened in response to winter pressures. At that time, in January 2023, Hull Royal Infirmary was placed under significant pressure in terms of admissions and staffing. The ward been open only a matter of some two weeks by the time Mrs [name redacted] was transferred to that ward. Despite being medically fit for discharge upon arrival on that ward Mrs [name redacted] condition worsened and family raised”
  2. 2. misidentification of author in discharge letter

    “An issue with the Lorenzo electronic patient record keeping system has been identified in respect of the system not auto populating the identification of the author of any changes made in the immediate discharge letter (IDL) after it has been finalised. This could lead to miscommunication of critical issues and difficulties in establishing who made what decisions which could lead to delays in treatment in the next post discharge setting which in turn could lead to future deaths.”

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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