Source · Prevention of Future Deaths
Judith Marsland
Ref: 2026-0329
Date: 10 Jun 2026
Coroner: Anna Morris
Area: Manchester South
0 responses identified · 1 indexed addressee
View PDF
AI-generated concerns summaryThere was an error in not escalating abnormal blood results, leading to patient deterioration, and key parts of the action plan for structured cross-team handovers and named responsible clinicians are not yet implemented.
Date
10 Jun 2026
56-day deadline
5 Aug 2026
stated in the report
Responses identified
0 of 1
Coroner's concerns
There was an error in not escalating abnormal blood results, leading to patient deterioration, and key parts of the action plan for structured cross-team handovers and named responsible clinicians are not yet implemented.
View full coroner's concerns
3) I heard evidence from [REDACTED], the lead investigator from the Trust PSII that Mrs. Marland’s deterioration and death followed an error in not escalating the abnormal blood results that were available for clinical review during her admission to Tameside Hospital on 7th November 2025. The PSII concluded that all blood results should have been reviewed and acted upon by the clinical teams that saw Mrs. Marsland and that she should not have been discharged home.
4) [REDACTED] evidence was that key aspects of the PSII action plan that are intended to mitigate the risk of future deaths are yet to be implemented by the Trust. In particular addressing the need for a structured cross-team handover from ED to speciality departments capturing clinical concerns, abnormal results, escalation plans, and creating named responsible clinicians.
4) [REDACTED] evidence was that key aspects of the PSII action plan that are intended to mitigate the risk of future deaths are yet to be implemented by the Trust. In particular addressing the need for a structured cross-team handover from ED to speciality departments capturing clinical concerns, abnormal results, escalation plans, and creating named responsible clinicians.
Report sections
Investigation and inquest
On the 4th November 2025, I commenced an investigation into the death of Judith Marsland. The investigation culminated in an inquest on the 9th June 2026. At the inquest, I found that Mrs. Marsland’s medical cause of death was
1a) Urosepsis and congestive cardiac failure 1b) Ischaemic heart disease 1c) Severe coronary arterial atherosclerosis II Chronic kidney disease stage 3, hypertension, chronic obstructive pulmonary disease.
On the 9th June, I returned a narrative conclusion at the inquest which found that Mrs. Marsland died at Tameside Hospital on the 14th November 2025 from the complication of sepsis, which developed from a urinary tract infection which had likely been present since at least the 6th November 2025, and having been discharged from the hospital on the 7th November during which time an infection was not identified or treated.
1a) Urosepsis and congestive cardiac failure 1b) Ischaemic heart disease 1c) Severe coronary arterial atherosclerosis II Chronic kidney disease stage 3, hypertension, chronic obstructive pulmonary disease.
On the 9th June, I returned a narrative conclusion at the inquest which found that Mrs. Marsland died at Tameside Hospital on the 14th November 2025 from the complication of sepsis, which developed from a urinary tract infection which had likely been present since at least the 6th November 2025, and having been discharged from the hospital on the 7th November during which time an infection was not identified or treated.
Circumstances of the death
Mrs. Marsland had a medical history which included heart failure and chronic kidney disease. In the 12 months prior to her death, she was treated for multiple urinary infections. It is likely that on or around the 6th November 2025 she was suffering from a urinary infection. On the 7th November Mrs. Marsland attended A&E at Tameside General Hospital and reported worsening intermittent bleeding and abdominal pain.
In the emergency department sepsis was considered but she was not managed on a sepsis pathway. Mrs. Marsland was transferred to the gynaecology hub for further review. Blood results that indicated acidosis and elevated inflammatory markers were not reviewed and acted upon by the gynaecology clinical team. As a result, Mrs. Marsland was discharged from hospital and was not prescribed antibiotics.
On the 12th November, Mrs. Marsland attended A&E with an increase of pain. Clinical assessment identified septic shock with multiorgan failure, and she was commenced on antibiotics. Her condition deteriorated and Mrs. Marsland died in hospital on the 14th November 2025.
In the emergency department sepsis was considered but she was not managed on a sepsis pathway. Mrs. Marsland was transferred to the gynaecology hub for further review. Blood results that indicated acidosis and elevated inflammatory markers were not reviewed and acted upon by the gynaecology clinical team. As a result, Mrs. Marsland was discharged from hospital and was not prescribed antibiotics.
On the 12th November, Mrs. Marsland attended A&E with an increase of pain. Clinical assessment identified septic shock with multiorgan failure, and she was commenced on antibiotics. Her condition deteriorated and Mrs. Marsland died in hospital on the 14th November 2025.
Action should be taken
In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe each of you have the power to take such action.
Copies sent to
I can confirm I have sent the report to
Similar PFD reports
Report details
- Reference
- 2026-0329
- Date of report
- 10 June 2026
- Coroner
- Anna Morris
- 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: 5 Aug 2026 (stated in the report).
Sent to
- Tameside and Glossop Integrated Care NHS Foundation Trust