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Margaret Spencer

29 Mar 2018 · Coroner Zafar Siddique · Black Country
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The coroner's concerns

  1. 1. lack of training on new IT system

    “Evidence emerged during the inquest that there were failures to properly implement sufficient training for staff during the introduction of a new IT system (Lorenzo). This resulted in the premature closing of her access plan and effectively no further review. This failure to conduct a review led to a number of patients including Mrs [name redacted] being placed at risk of harm.”

Responses

Margaret-Spencer-Response.pdf ↗· Walsall Healthcare NHS Trust

Stated action

“A report was generated via the Performance and Information Team which identified all the patients that had a pessary fitted during the calendar year of 2014. This report identified 602 patients having a vaginal pessary (ring and shelf) fitted during 2014. Out of these 602 patients, 7 had a shelf pessary fitted and had not received a follow up appointment. All 7 patients were reviewed by a consultant gynaecologist within a short”
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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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