John Hay
31 Mar 2026 · Coroner Hassan Shah · Northamptonshire
The coroner's concerns
1. risk assessment not completed nor reviewed with nursing or medical input
“The Risk Assessment in the Care Plan is neither completed nor reviewed with nursing or medical input, but includes, amongst other things, actions to be taken when a person is on blood thinners. In the present case, the only scenario covered was in relation to a person who has "heavy bleeding"”
2. escalation process unclear
“The process/system for escalation to get medical input was unclear”
3. medication notification process unclear
“The process/system by which missing or spent medication is actioned was unclear”