“Pennine Care NHS Foundation Trust”
Dated 22 Apr 2020, 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 publishedReplies were due by 17 Jun 2020.
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 dated22 Apr 2020
- Deadline17 Jun 2020
- Published on judiciary.uk18 May 2020
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Pennine Care NHS Foundation Trust | Response publishedPublished on judiciary.uk in May 2020. |
The coroner’s concerns
– (1) Pennine Care NHS Foundation Trust. The physical care of vulnerable patients on Summers Ward was poor. Whilst the experience of different junior doctors will inevitably vary, communication between the doctors and nurses was poor and the recording of clinical observations/ NEWS score and action thereon (designed to alleviate some of the clinical decision making) was inaccurate/ lacking. There was further confusion regarding the administration of oxygen, with at least one nurse being apparently unaware of the mandatory training.
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, 2020-0099
- 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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