“The inquest heard evidence that the way in which the scan was reported and then recorded…”
Dated 24 May 2021, 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 19 Jul 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 dated24 May 2021
- Deadline19 Jul 2021
- Published on judiciary.uk24 May 2021
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Tameside and Glossop Integrated Care NHS Foundation TrustNamed in the report as “Tameside & Glossop Integrated Care NHS Foundation Trust” | Response publishedPublished on judiciary.uk in May 2021. |
The coroner’s concerns
– 1. The inquest heard evidence that the way in which the scan was reported and then recorded was not clear and contributed to the treating clinician not appreciating the scan findings. 2. The documentation regarding clinical decisions taken including the decision to not follow the advice of the neurosurgeons was not documented in the notes. It was unclear if there was an expectation that where clinicians took a decision contrary to such advice how and in what detail the rationale should be recorded within the notes.
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, 2021-0168
- 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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