Source · Prevention of Future Deaths

Margaret Theresa Corrigan

Ref: 2013-0233 Date: 17 Sep 2013 Coroner: John Pollard Area: Manchester South Responses identified: 0 / 1 View PDF

Ineffective communication, a missed fracture diagnosis in the Emergency Department, and inappropriate ward placement for medical issues contributed to patient harm. Procedural errors, such as issuing an outpatient appointment to an inpatient, were also noted.

Date 17 Sep 2013
56-day deadline 23 Mar 2014 est.
Responses identified 0 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
Ineffective communication, a missed fracture diagnosis in the Emergency Department, and inappropriate ward placement for medical issues contributed to patient harm. Procedural errors, such as issuing an outpatient appointment to an inpatient, were also noted.
View full coroner's concerns
taken. as follows Communication between and among medical and nursing staff at your hospital was ineffective and lacked clarity: The patient was seen in the Emergency Department and it was agreed in evidence that the fracture ought to have been diagnosed at that time but it was not; thus meaning the patient was left for a further two in additional and at risk of further spinal damage 3_ The patient remained on the orthopaedic ward when she was suffering at that stage medical problems and ought properly to have been transferred to medical team_ Whilst she was an in-patient in the hospital, she was issued with an out-patient appointment to attend an orthopaedic clinic John $ Pollard LI.B. Hons, Senior Coroner Coroner's Court Mount Tabor; Mottram Street Joanne Kearsley LILB. Hons Grad Dip Psych, Area Coroner Stockport SKI 3PA Telephone: 0161 474 3993 Facsimile: 0161 474 3994 the Peg days pain from

In my opinion action should be taken to prevent future deaths and believe you have power to take such action: You are under a duty to respond to this report within 56 days of the date of this report namely by the 12 November 2013 and I, the Coroner; may extend that period. Your response must contain details of action taken or proposed to be taken setting out the timetable for such action otherwise you must explain why no action is proposed: have sent a copy of my report to the Chief Coroner and to daughter of the deceased am also under a duty to send to the Chief Coroner a copy of your response The Chief Coroner may publish either or both in 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 publication of your response by the Chief Coroner: therefore look forward to hearing from you within the time stipulated: Kours faithfully John S. Pollard Senior Coroner Cc to: Mrs Langshaw Crief Coroner 3_ Derek Winter, Senior Coroner the

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Report details

Reference
2013-0233
Date of report
17 September 2013
Coroner
John Pollard
Coroner area
Manchester South

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: 23 Mar 2014 (estimated).

Sent to

Stockport NHS Foundation Trust

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