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recurance

Amanda Ellams

7 Aug 2015 · Coroner John Pollard · Manchester (South)

The coroner's concerns

  1. 1. inadequate medical record keeping

    “standard of note keeping at the Alexandra Hospital (both medical and nursing) was well below that which would be generally regarded as satisfactory”
  2. 2. premature discharge with low oxygen saturation

    “Mrs [name redacted] was discharged from hospital even though it is now clear that her oxygen saturations were still too low for such discharge to take place.”
  3. 3. unanswered emergency calls to district nursing service

    “out-of-hours telephone system for the District Nursing team in Tameside area was operated by GTD Healthcare (which also provides the out-of-hours GP service in that area).”

Responses

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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.

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