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recurance

Sheldon Farnell

25 Mar 2021 · Coroner Derek Winter DL · City of Sunderland

The coroner's concerns

  1. 1. delayed recognition of sepsis

    “Guidance for the recognition of sepsis may be in need of expedited revision with protocols reflecting up to date NICE guidelines”
  2. 2. inadequate sepsis training

    “Sepsis training should be mandatory and delivered by doctors with relevant experience of current research and guidance”
  3. 3. delayed antibiotic prescribing

    “The messaging about the timely and prompt prescribing of antibiotic medication is in need of a review, as the Inquest highlighted issues of a possible overly cautious approach in their use, when there was no impediment to such use, and they may have saved [the deceased]'s life”
  4. 4. lack of family contact details

    “Contact details for families need to be positively given (not confirmed) at the time of admission and discharge within a hospital setting”

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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