“The case involved evidence of the in-patient treatment and care in circumstances where…”
Dated 12 Apr 2018, from the coroner for Manchester West. 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 7 Jun 2018. 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 dated12 Apr 2018
- Deadline7 Jun 2018
- Published on judiciary.uk14 Apr 2018
- Today27 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Northern Care Alliance NHS Foundation TrustNamed in the report as “Salford Royal NHS 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. The case involved evidence of the in-patient treatment and care in circumstances where that patient had brought into the hospital their own piece of important medical equipment — in this case a Continuous Positive Airway or “CPAP” machine (also known as an obstructive sleep apnoea machine); 2. Established medical practice, for good reasons, permitted patients to bring into the hospital and utilise their own “CPAP” machine with which the patient would be familiar; 3. However, the evidence that I heard revealed that there was no established system in place to ensure that such a piece of important medical equipment would remain with the patient in the event of transfer of that patient within the hospital from differing wards, units or departments; 4. Whilst I heard evidence that a comprehensive “Report following investigation” had been conducted by Salford Royal Hospital, facilitated by their Governance Manager, in which there was correctly identified the necessary potential root causes, conclusions and sharing of lessons, proposed monitoring mechanisms, ward to ward transfer documents and electronic record systems that had been put in place — nevertheless, the evidence that I received suggested that there were outstanding protocols and/or policies to be implemented to ensure that following an internal transfer, patient owned medical equipment such as the “CPAP” machine should not only be moved with that patient, but specific measures taken to ensure that it was both immediately available and ready for use to enable the patient to self-care upon completion of the transfer.
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, 2018-0214
- 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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