Paul Hardy

PFD Report 0 of 1 responses identified Ref: 2015-0041
Date of Report 4 February 2015
Coroner Stephanie Haskey
Coroner Area Nottinghamshire
Response Deadline est. 1 April 2015
State Custody related deaths
Judiciary.uk Report PDF
Coroner's Concerns (AI summary)
Healthcare staff failed to follow instructions for obtaining blood/urine samples for cancer investigation, neglected recommendations for INR monitoring, and did not conduct a Significant Event Analysis.
View full coroner's concerns
That there was a clear failure by Healthcare Staff to act upon instruction given by a visiting Advanced Nurse Practitioner to obtain and process blood and urine samples for the investigation of possible urological cancer 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 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 Paul Hardy:
Sent To
  • Nottinghamshire Healthcare NHS Trust
Responses Identified
Responses identified 0 of 1
56-Day Deadline 1 Apr 2015
About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Report Sections
Circumstances of the Death
Paul Hardy was a serving prisoner at HMP Lowdham Grange, operated by Serco, when he was confirmed by his local hospital as suffering from urological cancer. Whilst this was not; in the end, the immediate cause of his death, there were delays and errors in process whilst he was under the care of Lowdham Grange which caused unnecessary suffering and distress_
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe your organisation has the power to take such action my
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.