“To the Secretary of State for Health and Social Care 1 ) The court heard evidence from…”

The coroner’s concerns

To the Secretary of State for Health and Social Care 1 )  The court heard evidence from the Clinical Lead of SDEC as to a range of factors which he considers have contributed to increased attendances to the Trust’s urgent care services. I am concerned that one of the factors cited in evidence related to inability of some patients to obtain appointments at the GP practice they are registered with in a timely manner. 2)  It is understood from the evidence heard at inquest that NHS Trusts apply varying criteria as to which patients may be seen in an SDEC as opposed to an Emergency Department. It is a matter of concern from the evidence that there currently appears to be no national requirement which mandates early substantive face-to-face review by an experienced doctor or Advanced Practitioner prior to the streaming of a patient. To the Chief Executive, Tameside and Glossop Integrated Care NHS Foundation Trust 1 )  Notwithstanding the significant a mount of work the Trust has undertaken in the light of its investigation into the care afforded to Ms Ivers, it is a matter of concern that key familial history (such as early cardiac death of an immediate family member) is not automatically captured bythe initial contact with a clinician. 2)  I am concerned that patients who present to the Trust with chest pain do not routinely have their blood pressure checked in both arms as a matter of course. 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: [please do not use individual’s names, but instead roles/titles] 1)  Ms Ivers’s family; 2)  CareQuality Commission; and 3)  NHS Greater Manchester Integrated Care 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 box4 above for additional information relatingto the publication of reports and responses. SIGNATURE Paula Ivers – Prevention of future deaths report – 2026-0409_Published Download

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judiciary.uk, Prevention of Future Deaths reports, 2026-0409

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14 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