A North East hospital trust has been criticised by the coroner for delays in filling death reports after a 42-year-old man died from "multiple injuries". 

Jeremy Chipperfield, senior coroner for the area of County Durham and Darlington, strongly criticised trouble-hit Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) for "routinely failing" to employ procedures designed to prevent avoidable deaths. 

It comes after the death of one of their patients. Ian Darwin, 42, died from multiple injuries in Durham in March earlier this year. 

Mr Darwin's death was determined to be a serious incident, defined in NHS framework as “events where the potential for learning is so great, or the consequences to patients… so significant that they warrant particular attention to ensure these incidents... trigger actions that will prevent them from happening again”. They can be acts or omissions in care that result in "avoidable death". 

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The framework also sets out that serious incidents demonstrate "weaknesses in a system" that need to be addressed. 

This criticism comes as TEWV has faced scrutiny over a number of "preventable deaths" in their care.

Last month, the Trust pled guilty in connection with the deaths of two young women, Christie Harnett and Patient X. They are set to go to trial for the death of a third patient, Emily Moore, next year. 

This month, an inquest found that lapses in TEWV's care for 24-year-old Tom Creffield led to his self-inflicted death in his Redcar flat in early 2020. 

National guidelines about serious incidents state that they should be reported "without delay" and within "two working days of the incident being identified", and an investigation report finalised within 60 days of the incident first being reported. 

But despite this, TEWV did not appoint an investigator to look at Mr Darwin's death until over three months later, and the report into his death is not expected to be finished until mid-October. 

Coroner Jeremy Chipperfield said delays in death investigations are a "routine if not invariable" issue at TEWV.

He wrote: "TEWV serious incident death investigations, at all levels of seriousness, are routinely (if not invariably) significantly delayed and I understand there is no expectation of immediate, or any timetable for eventual rectification.

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"In some other cases, the delay is significantly longer than in the present; such delays affect cases of all levels of seriousness."

He went on to outline that action should be taken to prevent future deaths, and TEWV has been ordered to respond to the coroner's report with details of actions "taken or promised to be taken", alongside a timetable for this action. 

An inquest into Mr Darwin's death is yet to be heard.