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Mary Johnson

1 Feb 2019 · Coroner Hugh Bricknell · Herefordshire
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The coroner's concerns

  1. 1. lack of communication between staff

    “lack of communication between staff highlighted issues concerning: (a) the feeding of patients prior to operation (b) adherence to the Consultant's instructions regarding the provision of medication prior to operation”

Responses

2019-0458-Response-by-Wye-Valley-NHS-Trust.pdf ↗· Wye Valley NHS Trust

Stated action

“The plan, quite clearly placed in the notes by the consultant team, was for Mrs [name redacted] to be operated on Monday 23" July. Fortunately, this instruction appears not to have been read by the nurse caring for the patient over the weekend in question. This nurse appeared to have been under the impression that this patient was to be operated on over the weekend and hence withheld the prescribed thrombo prophelaxysis”
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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.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error