“is as follows”
Dated 25 Jun 2024, from the coroner for Manchester South. Sent to 3 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
Deadline passedReplies were due by 20 Aug 2024. A reply may have been sent and not yet published.
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.
- Report dated25 Jun 2024
- Deadline20 Aug 2024
- Published on judiciary.uk27 Jun 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Manchester City Council | Response publishedPublished on judiciary.uk in June 2024. |
| East Midlands Ambulance Service NHS TrustNamed in the report as “East Midlands Ambulance Service” | Response publishedPublished on judiciary.uk in June 2024. |
| Manchester University NHS Foundation Trust | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
The coroner’s concerns
is as follows. – (1) The inquest heard that there has been a change in policy with regards to the timing of discharge of patients from Manchester Royal Infirmary in circumstances where a patient is unable to manage independently when they arrive home. However, the Inquest heard that late discharges were still happening. In addition, the Inquest heard that the East Midlands Ambulance Service were unaware of the change in discharge timings. (2) Completion of the Serious Incident Review was delayed, and the report contained factual inaccuracies, giving rise to a concern relating to the approach taken by Manchester City Council to Serious Incident Reviews.
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, 2024-0339
- 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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