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recurance

Alexander Green

1 Apr 2019 · Coroner Maria Voisin · Avon

The coroner's concerns

  1. 1. failure to challenge and communicate effectively during handovers

    “The handover at around 8am resulted in a failure to challenge and communicate effectively. Handovers need to be considered across the whole of the trust not just the emergency department to ensure they are appropriate and effective.”
  2. 2. failure to apply appropriate head injury guideline

    “The NICE guideline for head injury was not considered appropriate for use in this case when it is clearly designed for exactly this case - you ascribe depressed conscious level to intoxication only after-a significant brain injury has been excluded.”
  3. 3. assumption of intoxication masking significant head injury

    “There was an assumption by everyone managing [name redacted] that he was intoxicated when in fact he had a significant head injury; SWAST | am told have developed training in relation to bias (and intoxication is included in that).”

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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