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Shirley Nightingale

16 Dec 2019 · Coroner Alison Mutch · Manchester (South)
Check this reportOriginal

The coroner's concerns

  1. 1. lack of escalation system for OGD lists

    “no clear system for escalation /prioritisation by treating clinicians in relation to management of the OGD lists and patient need where the OGD team said there was no capacity”

  2. 2. failure to follow up OGD referral before ward round

    “no clear system to ensure that this was followed up prior to the ward round on AMU the next day”

  3. 3. unrecorded decision without senior clinician agreement

    “rationale was not recorded and there was no system to ensure that a suitably experienced clinician agreed with the decision”

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.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error