Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0233, written 17 Sep 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Sep 2013 |
|---|---|
| Reference | 2013-0233 |
| Deceased | Margaret Theresa Corrigan |
| Coroner | John Pollard |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Stockport NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
Coroners Manchester South 17 September 2013 Chief Executive Stockport NHS Foundation Trust Poplar Grove Stockport SK2 7JE Our ref: JSP/KA/00777-2013 Your ref: Dear Chief Executive RE: Margaret Theresa CORRIGAN (Deceased) | write this letter to you pursuant to Regulation 28 of the Coroners (Investigation) Regulations 2013 and pursuant to paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009. On 26 March 2013 | commenced an investigation into the death of Margaret Theresa Corrigan who was born on 31 August 1924. The investigation concluded at the end of the Inquest on 6 September 2013 and the conclusion of the Inquest was that she died as a result of an Accidental Death. The medical cause of death given was 1a) Cerebellar and inferior parieto-occipital infarct due to 16) Vertebral artery dissection due to 1c) Peg fracture and under Part 2: Clostridium Difficile infection. The circumstances of the death were that on 18 January 2013 the deceased fell on the stairs at her home address and fractured her odontoid peg. During the course of the Inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you as follows 1. Communication between and among medical and nursing staff at your hospital was ineffective and lacked clarity. 2. The patient was seen in the Emergency Department and it was agreed in evidence that the fracture ought to have been diagnosed at that time but it was not, thus meaning the patient was left for a further two days in additional pain and at risk of further spinal damage. 3. The patient remained on the orthopaedic ward when she was suffering at that stage from medical problems and ought properly to have been transferred to a medical team. 4. Whilst she was an in-patient in the hospital, she was issued with an out-patient appointment to attend an orthopaedic clinic. John S Pollard LI.B. Hons, Senior Coroner Coroner's Court Mount Tabor, Mottram Street Joanne Kearsley LI.B. Hons Grad.Dip Psych, Area Coroner Stockport SK1 3PA Telephone: 0161 474 3993 Facsimile: 0161 474 3994 In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. You are under a duty to respond to this report within 56 days of the date of this report namely by the 12 November 2013 and |, the Coroner, may extend that period. Your response must contain details of action taken or proposed to be taken setting out the timetable for such action otherwise you must explain why no action is proposed. | have sent a copy of my report to the Chief Coroner and to daughter of the deceased. | am also under a duty to send to the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the Coroner, at the time of your response about the release or publication of your response by the Chief Coroner. | therefore look forward to hearing from you within the time stipulated. fol faithfully n S. Pollard Senior Coroner Cc to: 1. Mrs Langshaw 2. Chief Coroner 3. Derek Winter, Senior Coroner
See every Prevention of Future Deaths report matching Stockport NHS Foundation Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.