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recurance

Billy Longshaw

16 Mar 2022 · Coroner Chris Morris · Greater Manchester (South)

The coroner's concerns

  1. 1. failure to investigate care of patient who left ED without tests

    “Notwithstanding Mr [name redacted] died within 24 hours of being seen in the Emergency Department at Great Western Hospitals, Swindon, in circumstances where he was permitted to leave without basic blood tests being taken, any diagnosis being made, or serious abdominal pathology being fully excluded, it is a matter of concern that the Trust has not undertaken a detailed investigation into the care and treatment provided to him.”
  2. 2. flawed incident report based on incorrect assumption

    “The '48 Hour Report for Significant incidents resulting in Moderate Harm and above' prepared by an ED Consultant and others is fundamentally and obviously flawed (even when read against the Trust's own medical records), prefaced as it is by the assumption that 'the patient self-discharged against medical advice'.”
  3. 3. inadequate education on Mental Capacity Act 2005

    “Mr [name redacted] death raises issues as to the adequacy of education provided to medical students as to the Mental Capacity Act 2005, and doctors' of all levels familiarity with the practical application of this legislation in clinical settings, and accompanying guidance such as that produced by the General Medical Council in this regard.”

Responses

No published response was found on judiciary.uk.

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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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Billy Longshaw · Recurance