“In view of the fundamental importance of rigorous patient safety investigations whose…”
Dated 10 Jan 2019, 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
All responses publishedOrganisations 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.
- Report dated10 Jan 2019
- Deadline7 Mar 2019
- Published on judiciary.uk23 May 2019
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Stockport NHS Foundation TrustNamed in the report as “Stockport NHS Trust” | Response publishedPublished on judiciary.uk in May 2019. |
The coroner’s concerns
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— In view of the fundamental importance of rigorous patient safety investigations whose conclusions are capable of withstanding logical analysis to improving care, it is a matter of concern that the Trust's original investigation into the circumstances of Mr Shaw's fall (which had presumably passed through the Trust’s own quality assurance mechanisms) was manifestly and fundamentally flawed. Whilst the court heard evidence of significant improvements the Trust has made to the way it undertakes investigations, itis a matter of residual concern that the organisation has yet to launch a revised programme of investigation training for those who undertake patient safety inves Specifically in relation to cases involving falls, it remains of concern that frontline staff do not appear to have been provided with any guidance as to how to capture the best available evidence as to the circumstances of the fall as soon as reasonably possible after the incident. This is a matter of particular concern bearing in mind the potential benefits such an approach would bring to the Trust's ongoing efforts to understand the causes of falls on wards with a view to trying to prevent as ‘many of them as possible.
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, 2019-0007
- Added to Minute Book
- 8 Oct 2026
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- We show short extracts and link to the original. We don’t host the full report.
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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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