“Evidence was heard that the pathology sample was not followed up because despite…”
Dated 3 Feb 2021, from the coroner for Manchester North. 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 31 Mar 2021.
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 dated3 Feb 2021
- Deadline31 Mar 2021
- Published on judiciary.uk9 Feb 2021
- Today22 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Northern Care Alliance NHS Foundation TrustNamed in the report as “The Northern Care Alliance NHS Trust” | Response publishedPublished on judiciary.uk in February 2021. |
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.
- Evidence was heard that the pathology sample was not followed up because despite labelling the specimen to include the word malignancy the operating clinicians did not complete an online “suspected cancer upgrade form” at the time of surgery. However there were also many opportunities to identify and rectify the initial error which were also missed: 1. Appropriate consideration was not given to the deceased’s medical records at the time of her discharge from hospital. 2. The pathology report was not communicated to her general practitioner at the time she was discharged from hospital. 3. Appropriate consideration was not given to her records at the time that each outpatient appointment was cancelled As a consequence of the initial error and the missed opportunities the deceased was not referred for adjuvant chemotherapy until shortly before her death. Evidence was heard that an earlier referral would have prolonged her life.
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, 2021-0028
- 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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