“is as follows:- 1”
Dated 18 Oct 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 13 Dec 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 dated18 Oct 2021
- Deadline13 Dec 2021
- Published on judiciary.uk21 Oct 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 October 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.
is as follows:- 1. The Root Cause Analysis (RCA) undertaken by the Northern Care Alliance identified that a dose of Rasburicase had not been administered on 1 April 2021 however it did not consider any of the ___factors that gave rise to that omission or its consequences. My concern is that the RCA fell short of the required standard of rigour which leaves residual questions as to organisational governance standards and learning from death.
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, 2021-0348
- Added to Minute Book
- 8 Oct 2026
- Reuse
- 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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