“That information held on the NWAS system for the purpose of providing immediate guidance…”
Dated 24 Sep 2019, from the coroner for Manchester North. Sent to 2 organisations or people.
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 publishedReplies were due by 19 Nov 2019.
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; a reply may have been sent and not yet published.
- Report dated24 Sep 2019
- Deadline19 Nov 2019
- Published on judiciary.uk6 Nov 2019
- Today28 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| North West Ambulance Service NHS TrustNamed in the report as “North west Ambulance Service” | Response publishedPublished on judiciary.uk in November 2019. |
| Pennine Care NHS Foundation TrustNamed in the report as “Pennine Care NHS Trust” | Response publishedPublished on judiciary.uk in November 2019. |
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.
- That information held on the NWAS system for the purpose of providing immediate guidance to paramedics was 7 years out-of-date and was not known to or supported by the clinicians involved in this child’s care at the time of his death. Whilst | accept the evidence that paramedics will make a Clinical decision based on the patient’s presentation at the time, the fact that they sought advice around the existence of a DNA-CPR indicates that it is a relevant factor in their decision-making The evidence was that the number of children living tn the community with DNA-CPRs in place is small and there should be communication between the community paediatric teams and emergency services of any DNA-CPRs or Advance Care Plans that are in existence and are current.
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, 2019-0316
- 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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