Source · Prevention of Future Deaths
Norma Holden
Ref: 2016-0160
Date: 25 Apr 2016
Coroner: Jean Harkin
Area: Manchester City
Responses identified: 0 / 1
View PDF
The inquest identified matters of concern presenting a risk of future deaths if not addressed, requiring action by the relevant authorities.
Date
25 Apr 2016
56-day deadline
20 Jun 2016 est.
Responses identified
0 of 1
Coroner's concerns
The inquest identified matters of concern presenting a risk of future deaths if not addressed, requiring action by the relevant authorities.
View full coroner's concerns
During the inquest evidence was heard to the fact that Mrs Holden presented to the Accident and Emergency Department with history of abdominal pain: Triage stated swelling to face and mouth: It appears that mrs Holden had a swollen tongue and her speech was muffled. was unaware of the symptoms of swollen tongue and facial swelling: am concerned that the history taking is incomplete and not reported to treating doctors appropriately and that obvious symptoms applear to have not been noticed and actioned, such as possible anaphylactic shock, and appropriate tests conducted In addition, basic blood tests were not obtained for analysis of any infection/sepsis, to enable appropriate targeting of antibiotics. Action should be_taken In my opinion action should be taken to prevent future deaths and believe your organisation has the power to take such action: am concerned that lack of such basic observations and tests may affect the future management of patients and ask that you investigate and respond: Your response You are under a duty to respond to this report within 56 days of the date of this report, namely by 20 June 2016. I, the coroner; may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. history
Copies and publication have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The family of Mrs Holden am also under a duty to send the Chief Coroner a copy of your response_ The Chief Coroner may publish either or both in a complete or redacted or summary form: He may send a copy of this report to any person who he believes may find it useful or of interest: You may make representations to me, the coroner; at the time of your response, about the release or the publication of your response by the Chief Coroner: J Harkin Date AecX 2o(6 H.M: Area Coroner Manchester City Area
Copies and publication have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The family of Mrs Holden am also under a duty to send the Chief Coroner a copy of your response_ The Chief Coroner may publish either or both in a complete or redacted or summary form: He may send a copy of this report to any person who he believes may find it useful or of interest: You may make representations to me, the coroner; at the time of your response, about the release or the publication of your response by the Chief Coroner: J Harkin Date AecX 2o(6 H.M: Area Coroner Manchester City Area
Similar PFD reports
Related inquiry recommendations
Southport Inquiry
Response officer access to case information technology
Southport Inquiry
Healthcare trust risk information visibility
Southport Inquiry
GMMH and Alder Hey joint SMART audit
Southport Inquiry
National guidance on SMART action points
COVID-19 Inquiry
Data Systems for High-Risk Individuals
COVID-19 Inquiry
Proportionate Access to Linked Healthcare Records
Muckamore Abbey Inquiry
Full staff access to care plans
Muckamore Abbey Inquiry
Clear records and disclosure policies
Muckamore Abbey Inquiry
Regional service map with vacancies
Infected Blood Inquiry
Share Clinical Assessor Advice
Report details
- Reference
- 2016-0160
- Date of report
- 25 April 2016
- Coroner
- Jean Harkin
- Coroner area
- Manchester City
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 20 Jun 2016 (estimated).
Sent to
- University of Manchester NHS Foundation Trust