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Paul Hardy

4 Feb 2015 · Coroner Stephanie Haskey · Nottinghamshire
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The coroner's concerns

  1. 1. failure to obtain blood samples for INR monitoring

    “There was a failure to act upon a clear recommendation made by the Prison and Probation Ombudsman's Clinical Reviewer for facilitating the effective obtaining of blood samples for INR monitoring.”

  2. 2. failure to obtain and process blood and urine samples for urological cancer investigation

    “there was a clear failure by Healthcare Staff to act upon instruction given by a visiting Advanced Nurse [name redacted] to obtain and process blood and urine samples for the investigation of possible urological cancer.”

  3. 3. lack of Significant Event Analysis following death

    “There was a failure to act upon a clear recommendation made by the Clinical Reviewer that there should be a Significant Event Analysis of the events surrounding the death of [the deceased].”

Responses

No published response was found on judiciary.uk.

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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