“The evidence before the inquest was that the neurology service based at Salford Royal…”

The coroner’s concerns

– The evidence before the inquest was that the neurology service based at Salford Royal Hospital provided a service across Greater Manchester. However the notes kept by the neurology team were not stored on the patient’s notes but recorded on patient pass. This meant accessing the notes required recognising that patient pass needed to be accessed. In addition the evidence was that the detail within the neurology notes on patient pass was very limited and meant that it was difficult to fully understand the neurology advice given or the contact that there had been with neurology. As a consequence delivery of neurology care was disjointed and meant there was no clear neurology overview held by neurology. This impacted on the care that could be provided to patients and the provision of advice to other clinicians. Illustrative of this one neurologist was unaware that it was one of their neurology colleagues had diagnosed a neuro degenerative disease. This is exacerbated in relation to sites such as Trafford Hospital where all contact with neurology is via telephone or patient pass as there is no face to face neurology service.

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, 2024-0491

Added to Minute Book

8 Oct 2026

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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