Margaret Murphy: Prevention of future deaths report

Dear HM Coroner Name: Margaret Murphy Date of birth: 23/08/1943 Date of death: 09/10/2025 Firstly, on behalf of the Trust, I would like to express my sincere condolences to Mrs Murphy’s family for their loss. The Trust acknowledges the concerns raised during the course of the inquest in relation to offsite microbiology laboratory who undertake and report on blood cultures, and the fact that the orthopaedic notes were recorded in a Trauma and Orthopaedic ‘Tracker’, not routinely accessible to clinicians working in other specialities. As part of our ongoing service delivery model, some of the microbiology testing and associated laboratory services are provided by Manchester Foundation Trust (MFT). This arrangement was implemented following a detailed assessment of service requirements, workforce capacity, quality standards, financial considerations, and the need to ensure continued access to specialist microbiology expertise and diagnostic capabilities. MFT operates in accordance with all relevant regulatory, accreditation, and quality assurance requirements and maintains established protocols for specimen handling, analysis, reporting, and escalation of critical findings, ensuring continuity of service and patient safety. B3

[Page 2] The Trust acknowledges the importance of maintaining clear and current governance arrangements for outsourced microbiology services. The existing Service Level Agreement (SLA) between the Trust and MFT is currently under review and is being updated to reflect current service arrangements, operational requirements, roles, responsibilities, and escalation processes. The review process requires detailed consideration and agreement by both organisations to ensure that the document accurately reflects the services provided and the respective responsibilities of each party. As a result, completion of the revised SLA will take between 3- 6 months, as it must undergo the appropriate governance processes within both Trusts before it can be formally approved and ratified. Once ratification has been secured by both organisations, the updated SLA will be disseminated to relevant stakeholders and incorporated into existing governance and operational arrangements. In the interim, the microbiology service continues to operate under established contractual and operational processes, with regular communication and oversight mechanisms in place between the Trust and MFT to support service delivery and patient safety. Where specimens are referred to the external laboratory, clear procedures exist for transportation, chain of custody, result reporting, and communication between clinicians and laboratory staff. Any urgent or unexpected findings are escalated in accordance with agreed clinical pathways. It is noted that the current process is very much a manual process involving two lots of coded data i.e. one for TGH and one for MFT. However, both Trusts are working towards a new microbiology system where one code will be used across both organisations. This will reduce the time at the outset for both organisations, it will streamline the service further and audit data will be able to be reviewed more easily to ensure it is within the recommended timeframes. This new system is expected to be implemented from March 2027. The Trust conducted a review of the external microbiology service in August 2026 comprising of 33 patients from both GP and Trusts requests. This was to provide a representative spread of microbiology tests. this audit indicates that the main delays occur in the pre-analytics stage, in particular between sample request, registration onto Telepath/NPEX and registration on MFT's system. Microbiology specimens are transported via schedule collections throughout the day. Any clinically urgent samples are transferred directly to microbiology by taxi to avoid delays and ensure timely processing. From the August audit, delays of up to 24 hours were identified before samples entered the laboratory workflow once received at MFT, MRSA screens and urine cultures were generally reported within expected timescales. For a wound swab this would be 3 days, for a tissue sample this would be 5 days and for MRSA is 2 days. The audit represents only a snap shot of the activity, and the Trust are working closely with MFT to expand on this piece of work. We acknowledge the importance of timely and accurate microbiological testing in supporting clinical decision-making and safeguarding public health. Accordingly, we continue to monitor B4

[Page 3] the performance of the outsourced service and work collaboratively with the provider to maintain high standards of care. In relation to documentation, at the time of Mrs Murphy’s attendance, the orthopaedic review on 5th October 2025 was not documented on the Urgent Treatment Centre (UTC) clinical portal records and instead was recorded within the Trauma and Orthopaedic Tracker. This was despite the previous day's attendance being documented correctly on the same system. It was acknowledged by that treating clinician during the inquest that this was an individual error. Audits of the medical documentation in the UTC have been carried to measure against GMC expectation for accuracy, clarity, timeliness, relevance, confidentiality and support for care. The below table demonstrates the results of the audit: To strengthen communication between services and support continuity of care, key orthopaedic assessments, decisions, and management plans are now being consistently documented within the shared electronic patient record. Where specialty-specific trackers are required, clear processes are in place to ensure that important clinical information is transferred to the patient's main healthcare record. This would improve information sharing between Orthopaedics and the UTC, support informed clinical decision-making, and reduce the risk of important clinical information not being available to clinicians involved in the patient's assessment and treatment. Further considerations, learning and improvements have been made by way of:
• Shared documentation - Ensuring that key orthopaedic assessments, diagnoses, management plans, and follow-up arrangements are documented within the patient's main electronic health record (EHR), which is accessible to UTC, Emergency Department, and inpatient teams
• Standardised Communication Process – the Orthopaedic lead has introduced a requirement that significant orthopaedic decisions and management plans are B5

[Page 4] communicated through a standardised clinical note, handover entry, or electronic consultation response visible across specialties
• Staff Awareness and Training – communication has been disseminated to clinicians working within the UTC and other services to understand the ED Health Portal system in place and how to escalate if further training is required The Trusts acknowledges the concerns identified during the inquest and has taken the opportunity to strengthen both clinical areas to enhance continuity of care, support timely and informed decisions and contribute to patient safety by reducing the risk of important clinical information not being available which will continue to be monitored through the Trust’s audit process. I do hope that this letter provides you with further reassurance, however, should you have any queries arising from the content of this letter or require further information or clarification, please do not hesitate to contact Legal Services on

[Page 1] RESPONSE TO A REPORT TO PREVENT FUTURE DEATHS REGULATION 29 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 Please do not include any living persons’ names in this document, in accordance with the Chief Coroner’s PFD Publication Policy (2026). THIS RESPONSE IS BEING SENT TO: The Assistant Coroner, Christopher Murray for the Coroner Area of Manchester South in response to a ‘REPORT TO PREVENT FUTURE DEATH REGULATION 28’ following an inquest into the death of Margaret Murphy that concluded on 21 July
2026.
1. RESPONDENT In line with our duty under Regulation 29 of the Coroners (Investigations) Regulations 2013, NHS Greater Manchester Integrated Care Board provides this response within 56 days (plus any extension granted) of the date of the Report to Prevent Future Deaths.
2. DATE OF RESPONSE 1 October 2026
3. Thank you for the Regulation 28 Report sent to NHS Greater Manchester Integrated Care Board (NHS GM). I would like to say how sad we were to hear about the death of Ms Murphy and offer my sincere condolences to her loved ones. Thank you for highlighting your concerns following the inquest. I wanted to take the opportunity to respond to the matter of concern below that falls within our remit. CONFIRMATION OF CORONER’S MATTERS OF CONCERN The MATTER OF CONCERN is as follows: The court heard evidence that Tameside Hospital relies on an off-site laboratory to undertake and report on microbiology tests such as blood cultures. Whilst not a relevant factor in Ms Murphy's case, I am concerned as to the impact this system has on the time it takes relevant results to reach treating clinicians.
3. DETAILS OF ACTION TAKEN NHS GM recognises the importance of ensuring that microbiology services support the timely diagnosis and treatment of patients. NHS GM has reviewed the concern raised by the Coroner and considered the response provided by Tameside and Glossop Integrated Care NHS Foundation Trust. The Trust has outlined a number of actions already undertaken in response to the concern, including review of the service level agreement governing B7

[Page 2] microbiology services, audit work relating to blood culture processing and reporting, and ongoing work with Manchester University NHS Foundation Trust to strengthen arrangements and provide further assurance regarding turnaround times and escalation processes. NHS GM has reviewed the actions identified by the Trust and notes the planned implementation of a new laboratory information management system, together with the ongoing review of governance, reporting and escalation arrangements. NHS GM is satisfied that the Trust has recognised the concerns identified by the Coroner and has undertaken work to review the associated risks and identify opportunities for improvement.
4. DETAILS OF FURTHER ACTION PROPOSED NHS GM will continue to seek assurance through its existing quality, commissioning and contract management arrangements regarding the implementation of actions identified by the Trust. NHS GM will continue to monitor progress through established oversight arrangements and review any further actions or learning arising from the Trust's ongoing work in this area. Thank you for bringing these matters to my attention. I hope the above provides assurance regarding the actions taken and planned in response to the concerns raised. Please do not hesitate to get in touch if you require any further information. Deputy Chief Clinical Officer (Nursing and Nurse Advisor to the Board) NHS Greater Manchester B8