“A subdural haematoma was not identified in the report on the first CT scan [18:51 hours…”
Dated 7 Aug 2025, from the coroner for Manchester South. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 2 Oct 2025.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated7 Aug 2025
- Deadline2 Oct 2025
- Published on judiciary.uk13 Aug 2025
- Today23 Oct 2026
Watch this report
We’ll email you when a response is published on judiciary.uk, or when the 56 days to reply end with none published there yet. Free, and you can stop with one click.
Responses from each recipient
| Sent to | Response |
|---|---|
| Stockport NHS Foundation Trust | Response publishedPublished on judiciary.uk in August 2025. |
The coroner’s concerns
A subdural haematoma was not identified in the report on the first CT scan [18:51 hours on 22 nd March 2025, reported at 19:30 hours). The inquest heard that since this scan took place out of hours [i.e. between 17:00 and 09:00] hours it was dealt with by an out of hours service provided by a company called Medica. The rapid review which identified the haematoma after Kenneth Edwards’s death was conducted by one of the hospital’s own radiologists. Had the haematoma properly been identified at the time the first scan was reported, appropriate steps could have been taken to deal with it at a relatively early stage. Furthermore, this would have identified circumstances at an early stage of Kenneth Edwards’s treatment that militated against the administration of blood-thinning medication. Evidence was given that this was not the first time that detail had been missed on a scan reported upon by Medica. The administration of blood-thinning medication whilst awaiting the results of the second CT scan of the head to identify bleeding should not have happened. Whilst the treating clinician/s could not have known about the bleed that had not been identified on the first scan, they should have known that such medications were contra-indicated where the results of the second scan to identify brain bleeding were awaited. 7.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2025-0414
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
Something wrong, such as a date or who it was sent to? Report a mistake
Is this report about someone close to you? You can ask us to remove names from our pages.
Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
Ask about this report
AISummaries and questions, with page references. Pro and above.
Sign in to use