The Coroner
| Use attributes for filter ! | |
| First episode date | November 16, 2015 |
|---|---|
| No. of episodes | 20 (list of episodes) |
| Networks | BBC One |
| Composers | Debbie Wiseman |
| Dec 1, 2016 | |
| Reviews | www.imdb.com |
| Cast | Xavier Guelfi |
| Product compani | BBC Birmingham |
| No of seri | 2 |
| Origin releas | 16 November 2015 –; 2 December 2016 |
| Produc | Sandra McIver |
| Genres | Drama |
| Episodes | EpisodesS02 E10 · CrashDec 2, 2016 S02 E09 · Episode 9Dec 1, 2016 S02 E08 · Episode 8Nov 30, 2016 View 15+ more |
| Date of Reg. | |
| Date of Upd. | |
| ID | 1086441 |
About The Coroner
Alexandra, a medical examiner, deals with cases involving people who died under mysterious circumstances. She investigates to provide them justice even after facing opposition from her team.
Head teacher says autistic student died despite family's plea for support
... The Coroner said if children with complex needs were not given access to the care and treatment they needed, it was " predictable that a similar incident may arise"...
Ruth Perry: Inquest hears head felt humiliated after Ofsted inspection
... Asked by The Coroner whether she thought there was a link between the inspection and how Mrs Perry died, Mrs Leroy said " I believe there is yes"...
Waterbeach: The mystery over a baby found in a recycling tip
... " Meanwhile, The Coroner has suspended any inquest in the event the baby can be identified in the future...
Family of head teacher hope lessons can be learned
... " We are continuing to support The Coroner s inquest and we will give evidence at the hearing this week...
Betsi Cadwaladr health board criticised over Weetabix death
... Betsi Cadwaladr health board said it accepted The Coroner s findings...
NHS staff failed mum who died from drinking too much water
... " We are considering the findings of the jury and The Coroner...
Boy's asthma death was 'consequence of healthcare failures'
... His medication was not changed and he was not referred for further care, The Coroner was told...
Rory Kinnear calls for improvements to health and safety on set
... She s been campaigning to change health and safety regulation and training within the industry During the inquest The Coroner said: " The risk of Mr Milsome being harmed or fatally injured was not effectively recognised, assessed, communicated or managed...
Betsi Cadwaladr health board criticised over Weetabix death
By Sarah EasedaleBBC Wales news
A health board has been criticised for reacting too slowly when a coeliac patient died after eating Weetabix.
Hazel Pearson, 79, from Connah's Quay, Flintshire, died of aspiration pneumonia four days after being given the cereal for breakfast at Wrexham Maelor Hospital.
She fell ill hours after eating them on 26 November, 2021, and was sick.
Material from her stomach was breathed into her lungs, which caused an infection. She died on 30 November.
Coroner Kate Robertson told Ruthin coroner's court Mrs Pearson was known to be a coeliac, since it was in her records and her family repeatedly reminded staff about her condition.
Mrs Pearson would have accepted the meal believing it to be gluten free, said Ms Robertson.
Staff, She Said , should have known of the dietary restriction, adding that there were, " inadequate systems in place" amounting to a " gross failure".
A prevention of future deaths report will be issued to Betsi Cadwaladr health board as Ms Robertson considered there was still a risk deaths could occur.
For patients with food intolerances or allergies This Was , She Said , " insulting and dangerous"
Ms Robertson said: " Steps have been taken but progress has been far too slow. There are currently insufficient measures in place… training hasn't been delivered. "
Earlier, the health board's Steve Grayson told the hearing an online training programme on looking after coeliac patients had been uploaded on Wednesday.
Questioning the timing, Ms Robertson said it was " abhorrent" if that had happened because of the inquest rather than for patient safety.
She also criticised the lack of training given to staff on completing an NHS system used to record incidents about patient safety concerns.
The inquest heard Mrs Pearson, who had a weak heart and kidney disease, was initially admitted to Maelor hospital in August 2021 with shortness of breath.
She was later moved to Deeside community hospital for rehabilitation.
At Deeside, she was given meals containing gluten four times.
It was likely, said Ms Robertson, that she vomited Each Time though they were not all recorded on The System .
She was readmitted to Wrexham Maelor with hospital acquired pneumonia.
The inquest previously heard that, while Mrs Pearson's coeliac disease was noted on her admission documents, there was no sign over her bed indicating the condition.
That meant healthcare assistants were unaware of her dietary needs.
Ms Robertson reached a conclusion of misadventure, contributed to by neglect.
Betsi Cadwaladr health board said it accepted The Coroner 's findings.
Chief executive Carol Shillabeer said: " We Are implementing enhanced safety measures as a result in order to reduce the likelihood of these failures being repeated.
" We will review The Coroner 's concerns that have been raised and will respond detailing the actions we have taken and plan to take. "
Coeliac UK's Tristan Humphreys said Mrs Pearson's death reflected " a clear failure of care and it is patently unacceptable that This Was allowed to happen".
Related TopicsSource of news: bbc.com
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