Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate patient information handover between care settings
The earlier warning
Stephanie Daniels · 13 Dec 2013 · Nigel Meadows, Manchester City
“For new patients being admitted or transferred, there is no requirement for the nurse in charge to review their recent records.”
What was promised
Stated action 1 · response to Stephanie Daniels (13 Dec 2013) · stated timescale: none stated
“A revised governance process has been developed within the Citywide Commissioning, Quality and Safeguarding Team and the Trust now attends an established Citywide Patient Safety Committee. This committee meets monthly and is responsible for the review and monitoring of serious incidents requiring investigation reported by the Trust as well as any other patient safety related issues including those highlighted at inquest via Prevention of Future Death Reports.”
judiciary.uk/…/2013-0353-Response-by-Manchester-Clinical-Commis…
What recurred
- 8 May 2017 · Maud Patrick · Nigel Meadows · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Stephanie Daniels · 13 Dec 2013
“For new patients being admitted or transferred, there is no requirement for the nurse in charge to review their recent records.”
Later · Maud Patrick · 8 May 2017
“Transfer and hand over of a patient to AMU from A & E. There was no clear hand over process and review when the deceased arrived on the AMU.”
What happened next
No evidence found either way · stated action 1
“Figure 3 - Role of the Patient Safety Administrative Team in SIs Datix Form Received -Review and confirm grading of Serious Incident - whether externally reportable SI -Rate incident severity with the SI Panel Review Group members SI Notification -Never Event -All Never Events are SIs -Serious Incident -Notify relevant Clinical Governance Lead, Division /Directorate Manager and appropriate Executi”
[PDF] Serious Incident (SI) Policy · dbth.nhs.uk/document/corprisk15-2
“Patient safety incident response plan Effective date: 1st May 2026 Estimated refresh date:1st May 2028 NAME TITLE SIGNATURE DATE Author [name redacted] - Patient Safety & Complaints 31/3/2026 Reviewer Dr [name redacted] Director of Clinical Governance 23/4/2026 Authoriser Sohail Munshi [name redacted] -Jamieson Joint Chief Medical Officer [name redacted]”
Patient safety incident response plan · mft.nhs.uk/…/Patient-Safety-Incident-Response-Plan-April-2026.p…
No evidence found does not mean the action did not happen.