Linda Brooks
6 Feb 2026 · Coroner Deborah Archer · Devon, Plymouth and Torbay
The coroner's concerns
1. lack of training and understanding by staff
“There appeared to be a lack of training and understanding by staff at the Trust that it is everybody's responsibility to report and escalate a serious clinical incident such as this”
2. no effective process for reviewing clinical notes
“There appears to be no effective process in place for reviewing clinical notes to pick up a clinical issue such as this in circumstances where no complaint has been made by a family member, and no member of staff has recognised or reported it”
3. lack of understanding of Serious Incident Report timing
“There appears to be a lack of understanding as to when a Serious Incident Report should be made or actioned retrospectively”
4. no process for recording SWAST Datix referral
“There appeared to be no process for recording the fact that another organisation such as SWAST had made a Datix referral which would then have mitigated the fact that the SWAST Team failed to pass on their own DATIX to Torbay and South Devon NHS Trust”