“The inquest was told that the ward in question had been short staffed for a number of…”
Dated 27 Apr 2020, from the coroner for Manchester South. 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 22 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 dated27 Apr 2020
- Deadline22 Jun 2020
- Published on judiciary.uk5 Jun 2020
- 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 Foundation Trust (MFT)” | Response publishedPublished on judiciary.uk in June 2022. |
| Department of Health and Social Care | Response publishedPublished on judiciary.uk in June 2022. |
The coroner’s concerns
– 1. The inquest was told that the ward in question had been short staffed for a number of months. As a result there was a reliance on agency staff and less experienced staff. The trust was now seeking to resolve the issue but it was still not fully resolved. It reflected a wider issue of a national shortage of nurses. 2. The inquest was told that whilst Mrs Ross was medically fit for discharge prior to 1st July she had not been discharged because of delays in arranging a suitable care package to support her in the community. 3. During the course of the inquest the documentation relied on by the trust was lacking in detail and meant that it was difficult to understand her condition at key points or to understand the rationale for decisions. 4. The inquest heard that the Trust had not followed their own falls risk policy in relation to Mrs Ross. 5. There did not appear to be a clear system of regular orthogeriatric consultant reviews of Mrs Ross. This meant that there was no escalation of her condition to a consultant when she began to show signs of deterioration.
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, 2020-0106
- 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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