Recurance · prevention of future deaths reports
Pre-inquest brief
Delayed trans-oesophageal echocardiogram availability and staffing
The earlier warning
Michael Amesbury · 19 Jul 2023 · Alison Mutch, Manchester South
“The use of different systems and reliance on postal services and lack of a clear, effective electronic system of referrals including transfer of images /notes meant there were delays in assessing patients”
judiciary.uk/…/michael-amesbury-prevention-of-future-deaths-rep…
What was promised
Stated action 1 · response to Michael Amesbury (19 Jul 2023) · stated timescale: October 2023
“We are looking at how we can bring the benefits of this type of technology to other services.”
judiciary.uk/…/2023-0259-Response-from-Greater-Manchester-Integ…
What recurred
- 2 Jul 2024 · James Cockburn · Alison Mutch · Closely related · confidence 0.85 (high)
The clearest link, quoted from both reports:
Earlier · Michael Amesbury · 19 Jul 2023
“The use of different systems and reliance on postal services and lack of a clear, effective electronic system of referrals including transfer of images /notes meant there were delays in assessing patients”
Later · James Cockburn · 2 Jul 2024
“significant wait times for essential tests such as trans oesophageal echocardiograms to be carried out due to a shortage of suitably quailed professionals”
What happened next
No web check of the stated actions has been published for this chain.