“The inquest heard that there was no clear system for escalation /prioritisation by…”
Dated 16 Dec 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 10 Feb 2020. 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 dated16 Dec 2019
- Deadline10 Feb 2020
- Published on judiciary.uk31 Dec 2019
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Tameside and Glossop Integrated Care NHS Foundation TrustNamed in the report as “Tameside and Glossop Integrated Care NHS Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 10 Feb 2020. 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. The inquest heard that there was no clear system for escalation /prioritisation by treating clinicians in relation to management of the OGD lists and patient need where the OGD team said there was no capacity; 2. The inquest heard that it had been identified in Accident and Emergency that the OGD was required. The notes were marked accordingly but there was no clear system to ensure that this was followed up prior to the ward round on AMU the next day; 3. When a decision was made to depart from the recognised best practice timescales the rationale was not recorded and there was no system to ensure that a suitably experienced clinician agreed with the decision.
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, 2019-0431
- 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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