“The inquest heard that whilst contact was made with the Neurosurgical team at Salford…”
Dated 7 Oct 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 2 Dec 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 dated7 Oct 2020
- Deadline2 Dec 2020
- Published on judiciary.uk1 Dec 2020
- Today23 Oct 2026
Watch this report
We’ll email you when a response is published on judiciary.uk, or when the 56 days to reply end with none published there yet. Free, and you can stop with one click.
Responses from each recipient
| Sent to | Response |
|---|---|
| Manchester University NHS Foundation Trust | Response publishedPublished on judiciary.uk in June 2022. |
The coroner’s concerns
1. The inquest heard that whilst contact was made with the Neurosurgical team at Salford Raval Hosoital on the dav of her admission there was 1 no conversation with a Doctor from that team until the day after her admission. As a result there was no expert neuro input into her care for 24 hours. There was no evidence that there was any attempt to chase up contact earlier. 2. Mrs Jeanes was brought into hospital by ambulance at the direction of a GP who recognised that she had a suspected head injury and was on warfarin. The GP recognised that the NICE guidance suggests there is an 8 hour window for patients on warfarin with a suspected head injury. Her fall had been at 23.58 on 161h March. The inquest heard that she was triaged but her CT scan was not ~xpedited and was not reported on until 11.45 almost 12 hours after the fall. There was no evidence of a system that would fast track such cases for a CT scan. 3. The inquest heard that haematology advice on the day of admission was to reduce her INR. This advice was reconfirmed by the neuro surgeons the following day. There were differences in the recommendations and it was not entirely clear how that difference was being managed. In any event despite repeated attempts with Vitamin K Mrs Jeanes INR remained above the target. Further advice from the haematologist was not sought until 26th March some 9 days after her admission. It was unclear why that delay had occurred as the notes suggested it had been recognised that advice should have been sought previously but this had not been followed up. There was no evidence before the inquest of what system was in place or who would take responsibility for follow up in such a situation.
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, 2020-0200
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
Something wrong, such as a date or who it was sent to? Report a mistake
Is this report about someone close to you? You can ask us to remove names from our pages.
Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
Ask about this report
AISummaries and questions, with page references. Pro and above.
Sign in to use