“The inquest heard that despite the referral being in August 2022 he had to wait months…”
Dated 2 Jul 2024, from the coroner for Manchester South. Sent to 2 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
All responses publishedReplies were due by 27 Aug 2024.
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 dated2 Jul 2024
- Deadline27 Aug 2024
- Published on judiciary.uk4 Jul 2024
- Today27 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 |
|---|---|
| NHS Greater Manchester Integrated Care BoardNamed in the report as “Greater Manchester Integrated Care” | Response publishedPublished on judiciary.uk in July 2024. |
| NHS England | Response publishedPublished on judiciary.uk in July 2024. |
The coroner’s concerns
– The inquest heard that despite the referral being in August 2022 he had to wait months for his appointment due to the demand on cardiac services. This was significant across Greater Manchester but reflected a national picture of significant delays in patients waiting to see a cardiologist. As a consequence patient/s with cardiac issues are subject to delays in treatment plans and decision making regarding suitability for potentially lifesaving surgical procedures. In Mr Cockburn’s case he died whilst waiting assessment for his suitability for open heart surgery. It was 9 months since the first referral. The position the inquest was told is exacerbated due to significant wait times for essential tests such as trans oesophageal echocardiograms to be carried out due to a shortage of suitably quailed professionals to carry them out. 6 In his case the position was further exacerbated by delays in communication between two different trusts – NCA and MUFT. Their IT systems are completely separate and cannot transmit information into the others patient records easily. This meant that it was almost a month before the system at MUFT was updated with the test results from Salford Royal.
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, 2024-0352
- 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