Margaret Templeman
20 Jul 2026 · Coroner Rebecca Mundy · Essex
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. inadequate clinical record keeping
“Inadequate Clinical Record Keeping”
2. failure to document communication and escalation
“Failure to Document Communication and Escalation”
3. reliability of patient safety assurance processes
“Reliability of Patient Safety Assurance Processes”
4. trust-wide nature of the issue
“Trust-Wide Nature of the Issue”
Linked reports
Identical hazardConfidence 0.95 · high
Earlier report
“Accuracy of record keeping - Training and procedures in respect of how communications should occur between all clinical personnel in the delivery theatre”
This report
“During the course of this investigation I heard evidence of significant deficiencies in the maintenance of clinical records relating to hydration, nutrition, communication, observations, medication management and aspects of clinical decision making.”
Closely relatedConfidence 0.90 · high
Earlier report
“d. Communication issues with Trust staff and sharing of information”
This report
“I am concerned that the documentation and communication failures identified in this case may not be confined to a single ward, clinical team or hospital site.”