“Mary Jones was a frail elderly lady who was moved from the MRI to Trafford General…”
Dated 30 Sep 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
Deadline passedReplies were due by 25 Nov 2019. 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 dated30 Sep 2019
- Deadline25 Nov 2019
- Published on judiciary.uk8 Nov 2019
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Manchester University NHS Foundation TrustNamed in the report as “Manchester University NHS Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 25 Nov 2019. A reply may have been sent and not yet published. |
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. Mary Jones was a frail elderly lady who was moved from the MRI to Trafford General post-operatively for rehabilitation under the Trust structure. It was a planned transfer. However due to limited transport availability she arrived at Trafford General out of hours after waiting for transfer. As a result she was clerked in and risk assessed out of hours despite the recognised risks of moving frail elderly patients out of hours. The inquest was told that this is not uncommon as transfers such as these are made via ambulance and are low priority and moved where needed; 2. The falls risk assessment was completed outside the Trust target time primarily as a result of the late arrival; 3. The documentation within the nursing notes, particularly the fluid charts was poor quality, making it difficult to understand what had happened in relation to the hydration of Mrs Jones; 4. The documentation issue was exacerbated by the Trust IT merger having resulted in the loss of a number of key documents. It was unclear how the Trust were managing the risks around lost medical records where the IT merger was at the root of the issue; 5. Despite her frailty there was no evidence available at the inquest of a referral to a dietician/nutritionist. There was to have been a referral to SALT in February but no trace could be found of the referral: 6. There was no evidence of clear clinical review of the outcome of the fluid charts.
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, 2019-0322
- 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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