“On the ‘office’ receiving a call from a carer reporting, as here, that a client appears…”
Dated 3 Sep 2025, from the coroner for Manchester South. Sent to 3 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 29 Oct 2025. A reply may have been sent and not yet published.
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.
- Report dated3 Sep 2025
- Deadline29 Oct 2025
- Published on judiciary.uk5 Sep 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 |
|---|---|
| Secretary of State for Health and Social Care | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 29 Oct 2025. A reply may have been sent and not yet published. |
| Department of Health and Social Care | Response publishedPublished on judiciary.uk in September 2025. |
| Care Quality CommissionNamed in the report as “Chief Executive, Care Quality Commission” | Response publishedPublished on judiciary.uk in September 2025. |
The coroner’s concerns
– 1. On the ‘office’ receiving a call from a carer reporting, as here, that a client appears to be unwell there is no algorithm for the call handler (who tends to be an assistant manager/manager but with no medical background) to follow to triage the client, setting out why the client appears unwell and to then determine a course of action. The direction of the conversation is simply left to the ‘office’. 2. There was no ability for the carer reporting that Margaret was unwell to carry out any basic observations, neither before the call to the office nor after it, in order that Margaret could be monitored as per the advice given or to at least provide a baseline for monitoring, not even a temperature reading. Most family homes, caring for children or physically vulnerable adults, would have at least a thermometer, and perhaps a pulse oximeter, maybe even a blood pressure machine.
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, 2025-0448
- 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