“To the Secretary of State for Health and Social Care 1”

The coroner’s concerns

To the Secretary of State for Health and Social Care 1. A consultant in medical microbiology gave evidence as to a national shortage of doctors of that specialism in the NHS. Given the significance of microbiology to modern medicine, I am concerned any such shortage creates a risk of future deaths. To the Chief Executives of Greater Manchester Integrated Care Partnership and Tameside and Glossop Integrated Care NHS Foundation Trust 2. The court heard evidence that Tameside Hospital relies on an off-site laboratory to undertake and report on microbiology tests such as blood-cultures. Whilst not a relevant factor in Miss Murphy’s case, I am concerned as to the impact this system has for the time it takes relevant results to reach treating clinicians. To the Chief Executive of Tameside and Glossop Integrated Care NHS Foundation Trust 3. Having reviewed Miss Murphy in the Same Day Emergency Care Unit on 5 October 2025, the Orthopaedic Senior House Officer wrote their notes in a Trauma and Orthopaedic ‘Tracker’, not routinely accessible to clinicians working in other specialities. I am concerned as to the risk of future deaths which arises from the creation of an extra layer of documentation not easily visible to others in the hospital, particularly in the context of an already disjointed and labyrinthine system for capturing clinical information. 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. Miss Murphy’s family; 2. Weightmans LLP; and 3. Care Quality Commission. 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 Margaret Murphy – Prevention of future deaths report – 2026-0412_Published Download

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, 2026-0412

Added to Minute Book

14 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