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recurance

Stephen Stringer

15 Oct 2024 · Coroner Alison Mutch · Manchester South

The coroner's concerns

  1. 1. information not recorded in patient record

    “Patients contacting the surgery had to select which stream within the practice their enquiry went to. It was not always clear from the headings whether the query would be seen by a GP or the admin team. Information that went into the admin work stream from a patient did not go onto the patient record and was not seen by a doctor”
  2. 2. persistent hoarse voice not recognised as cancer red flag

    “it was important that where a patient presented with a hoarse voice that all health professionals explored for how long it had been an issue and whether there was a realistic treatable cause for it. In the absence of any clear cause such as a throat infection or where there was no clear response to treatment then a hoarse voice should be seen as a red flag symptom for laryngeal cancers and result in a referral on the 2 week wait”
  3. 3. lack of coordinated oversight of patient deterioration

    “A number of different health professionals had input into his care. This meant that there was no one health professional who had a good insight into his overall deterioration and symptoms. Where multiple practitioners were involved one person needed to maintain oversight or the electronic patient record needed to have easily accessible clear action plans and notes were required so that a patient and their symptoms could be seen holistically rather than a one off”
  4. 4. low public awareness of voice change as cancer symptom

    “there is limited public awareness of how significant a change in voice can be and recognising it as a potential cancer symptom. Greater public awareness of symptoms of laryngeal cancers would ensure the public were better placed to seek help at an early stage”

Responses

2024-0555-Response-from-Derby-and-Derbyshire-Integrated-Care-Board-.pdf ↗· NHS Derby and Derbyshire Integrated Care Board

Stated action

“The practice involved in this inquest had taken steps since identifying the issue to mitigate the risks.”

Stated action

“In the absence of any clear cause such as a throat infection or where there was no clear response to treatment then a hoarse voice should be seen as a red flag symptom for laryngeal cancers and result in a referral on the 2 weeks wait.”

Stated action

“A number of different health professionals had input into his care. This meant that there was no one health professional who had a good insight into his overall deterioration and symptoms.”

Stated action

“Greater public awareness of symptoms of laryngeal cancers would ensure the public were better placed to seek help at an early stage.”

2024-0555-Response-from-DHSC.pdf ↗· Department of Health and Social Care

Stated action

“Call routing enables patients to choose options via their keypad or voice options to enable direct routing to the right person or team. When properly configured, these systems can divert some demand away from phones at busy times, making it easier to get through to someone to book an appointment.”
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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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