“I heard evidence from , the lead investigator from the Trust PSII that Mrs”
Dated 10 Jun 2026, 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
Report put online after its 56 daysOrganisations 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.
judiciary.uk put this report online on 2 Sep 2026, after the 56 days for replies had ended (5 Aug 2026). These dates can’t tell us whether a reply was due before it went online. A reply may have been sent and not yet published.
- Report dated10 Jun 2026
- Deadline5 Aug 2026
- Published on judiciary.uk2 Sep 2026
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Tameside and Glossop Integrated Care NHS Foundation Trust | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 2 Sep 2026, after the 56 days for replies had ended (5 Aug 2026). These dates can’t tell us whether a reply was due before it went online. |
The coroner’s concerns
3) I heard evidence from , the lead investigator from the Trust PSII that Mrs. Marland’s deterioration and death followed an error in not escalating the abnormal blood results that were available for clinical review during her admission to Tameside Hospital on 7th November 2025. The PSII concluded that all blood results should have been reviewed and acted upon by the clinical teams that saw Mrs. Marsland and that she should not have been discharged home. 4) evidence was that key aspects of the PSII action plan that are intended to mitigate the risk of future deaths are yet to be implemented by the Trust. In particular addressing the need for a structured cross-team handover from ED to speciality departments capturing clinical concerns, abnormal results, escalation plans, and creating named responsible clinicians. 10. COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: 1. Mrs. Marsland’s Family 2. The Millgate Healthcare Partnership I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. SIGNATURE
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, 2026-0329
- Added to Minute Book
- 8 Oct 2026
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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