“DK’s medical care on ward D2 was poor and probably contributed to his death”
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 |
|---|---|
| Stockport NHS Foundation Trust | Response publishedPublished on judiciary.uk in May 2020. |
The coroner’s concerns
– (1) DK’s medical care on ward D2 was poor and probably contributed to his death. (2) Between 24th and 26th April DK was allowed to become increasingly dehydrated; on 24th April he received a total of 300mls of fluid and the input/output chart was not filled in on 25th/26th April, despite the fact that he was seriously unwell. (3) There were few clinical observations on this sick patient. On 26th April, clinical observations were performed at 11.12 (MEWS 1) and 21.06 (MEWS 0). There were no clinical observations thereafter. No protocol was produced regarding the frequency of observations in sick patients on Ward D2.
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, 2020-0100
- 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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