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recurance

Lack of communication between specialties and roles

Closely relatedConfidence 0.90 · high2 reports · 2018–2024No published response to an earlier report One-page brief (print or PDF)

Manchester University NHS Foundation Trust received 2 coroners' reports about this hazard between 16 Jul 2018 and 19 Jun 2024.

They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.

No published response from Manchester University NHS Foundation Trust was found for the earlier reports.

2
reports
2
different coroners
2018–2024
years
0.90
lowest link confidence

The story, report by report

Spacing grows with the time between reports.

  1. First warning

    Sheila Ridgway↗

    16 Jul 2018 · Rashid Sohall · Manchester (City)

    “Communication between speciality consultants ~ lack of any system to ensure that communication occurs between the treating consultants as to the necessity for identifying and documenting any potential ongoing risks”
    Original on judiciary.uk ↗

    No published response from Manchester University NHS Foundation Trust was found for this report.

  2. 5 years 11 months later

    Raised again · 1st time

    Thomas Gibson↗

    19 Jun 2024 · Chris Morris · Manchester South

    Closely relatedConfidence 0.90 · higha different coroner
    “there does not appear to be clear guidance available to those working within the Trust as to what is required when communicating (particularly as to test results and a patient's presentation) as between different specialisms and as between different roles within the team.”
    Original on judiciary.uk ↗

    Manchester University NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗

    “we have focused on the Human Factors of errors in clinical medicine and have engaged with our Human Factors Academy (HFA). This will support us to understand better the other factors at play which contribute to incorrect ECG interpretation; and which can be mitigated in the future. 1”

    Stated timescale: 2024-08-08

  3. All reports to Manchester University NHS Foundation Trust

Next

This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error