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recurance

Patrick Steer

23 Nov 2016 · Coroner Rachael Griffin · Manchester (West)

The coroner's concerns

  1. 1. communication breakdown between surgical and coronary care teams

    “During the inquest evidence was heard that: i. Mr [name redacted] had been treated by a number of different clinicians with different expertise including members of the Cardiology team and the Surgical team. He was initially treated by the Surgical team on the surgical ward and was stepped down to ward level care on the 15" May. He was then transferred to the Coronary Care Unit on the 18 May following a myocardial infarction. ii. | He continued to be reviewed both by the Surgical team and the Coronary”
  2. 2. absence of clear communication policies for shared care

    “I therefore request that a review is undertaken of any policies and procedures in place dealing with the communication between doctors caring for a patient where then is shared care between the Cardiology team and the Surgical team. I would also request that all members of Wrightington, Wigan and Leigh NHS Trust are made aware of the policies and procedures in place dealing with communication between medical staff when dealing with patients under shared care.”
  3. 3. communication failure in shared care

    “I have concerns with regard to the following: i. That in circumstances where a patient is under the care of both the Surgical and Coronary Care teams, communication between the Doctors of those teams does not work well and could affect the treatment a patient receives which could lead to a future death.”

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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