“She was discharged from hospital after being started on the Septrin without allowing…”
Dated 23 Feb 2016, 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
Deadline passedReplies were due by 19 Apr 2016. 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 dated23 Feb 2016
- Deadline19 Apr 2016
- Published on judiciary.uk23 Feb 2016
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Stockport NHS Foundation Trust | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
— 1. She was discharged from hospital after being started on the Septrin without allowing sufficient time to ensure that the new drug “suited” her. 2. She was advised for teicoplanin on the 8" April at 17.10 hours yet she had not even been given the first dose thereof by 15.56 hours on the 9"" April. 3. There was a 48 hour delay in her being given any antibiotics, 4. The junior doctor gave evidence that s/he was unable to “get round to seeing” this patient as there was insufficient doctor-time to do so on that shift. The doctor went on to say “this is not an uncommon situation”. The hospital as a whole was being covered by one FY1 doctor and two SHO’s, one of whom was ‘clerking in’ the new patients. This meant that the FY1 was covering 13 wards of the hospital. Clearly an impossible task. 5._In general terms the matron reporting the Root Cause Analysis agreed that on a scale of one to ten, where one is appalling and ten is excellent, “this case was very low down the scale indeed”. 6. The “Escalation guidelines for the iBleep system were either unknown to the staff or were not adhered to. 7. There was an acknowledged shortage of nurses at the time. 8. The pharmacy staff did not give precise details of the drug which they were dispensing and the potential side effects thereof. 9. The handover sheets on the ward are “shredded by the nurses” immediately after handover. Why cannot these be kept in a folder on the ward for at least 14 days should they be needed for reference Purposes? | was told of the transition from paper to electronic notes. This seems to have been happening for a very long time and one wonders when it will be complete.
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, 2016-0080
- 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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