Paula Ivers
26 Aug 2026 · Coroner Chris Morris · Manchester South
The coroner's concerns
1. inability of some patients to obtain timely GP appointments
“The court heard evidence from the Clinical Lead of SDEC as to a range of factors which he considers have contributed to increased attendances to the Trust's urgent care services. I am concerned that one of the factors cited in evidence related to inability of some patients to obtain appointments at the GP practice they are registered with in a timely manner.”
2. lack of national requirement for early substantive face-to-face review before SDEC streaming
“It is understood from the evidence heard at inquest that NHS Trusts apply varying criteria as to which patients may be seen in an SDEC as opposed to an Emergency Department. It is a matter of concern from the evidence that there currently appears to be no national requirement which mandates early substantive face-to-face review by an experienced doctor or Advanced Practitioner prior to the streaming of a patient.”
3. failure to capture key familial cardiac history at initial contact
“Notwithstanding the significant a mount of work the Trust has undertaken in the light of its investigation into the care afforded to Ms [name redacted], it is a matter of concern that key familial history (such as early cardiac death of an immediate family member) is not automatically captured bythe initial contact with a clinician.”
4. routine omission of bilateral blood pressure measurement for chest pain patients
“I am concerned that patients who present to the Trust with chest pain do not routinely have their blood pressure checked in both arms as a matter of course.”