Michelle Dawes

The report

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REPORT TO PREVENT FUTURE DEATHS 
REGULATION 28 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 
2013 

Please do not include any living persons’ names in this document, in 
accordance with the Chief Coroner’s PFD Publication Policy (2026). 

1.  CORONER 

I am Isobel Thistlethwaite, Assistant Coroner for The Black Country Jurisdiction.  

2.   DATE OF REPORT 
24 April 2026  

3.  CORONER’S LEGAL POWERS 

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice 
Act 2009 and regulations 28 and 29 of the Coroners (Investigations) 
Regulations 2013. 

3.  THIS REPORT IS BEING SENT TO 

1. Walsall Healthcare NHS Trust 

You are under a duty to respond to this report within 56 days of the date of this 
report, namely by 19th June 2026. I, the coroner, may extend the period if an 
appropriate application is made. 

4.   YOUR RESPONSE 

Your response must contain details of action taken or proposed to be taken, 
setting out the timetable for action. Otherwise, you must explain why no action 
is proposed. 

I have a duty to send a copy of your response to the Chief Coroner. 

In accordance with the Chief Coroner’s Publication Policy, you should send me 
any representations regarding publication of your response. These 
representations should be made at the same time as the response is provided. 
I will pass any representations received to the Chief Coroner for a decision. 

Please note any links to webpages included in the response will not be 
checked for sensitive information prior to publication, as the information is 
already online. 

The names of those who do not respond to PFD reports are regularly 
published on the Chief Coroner’s webpages Non-responses to Prevention of 
Future Death (PFD) reports - Courts and Tribunals Judiciary. 

5.  SUMMARY OF CORONER’S CONCERN 

I am concerned that despite the Trust acknowledging missed opportunities and 
delays and identifying required improvements, it will take up to twelve months 
after Mrs Dawes’ death to fully implement those changes, with no interim 
measures in place, thereby undermining learning from deaths and leaving an 
ongoing risk to patient safety. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 6.  ACTION SHOULD BE TAKEN 

In my opinion unless action is taken to address the above concerns then there 
is a significant risk of future deaths and I believe each of you have the power 
to take such action. 

7. 

INVESTIGATION AND INQUEST 

On 18/7/25, I commenced an investigation into the death of Michelle DAWES, 
aged 55 years. 

The medical cause of death was  

Cause of death 1a Respiratory failure 
Cause of death 1b Granulomatous inflammatory disease 

How, when and where 

Mrs Dawes was a 55 year old female who presented to hospital on 3 June 
2025, the working diagnosis at that time was community acquired pneumonia. 
She was discharged with antibiotics and a plan to have a repeat chest x-ray in 
six weeks. On 8 July 2025 she represented to hospital with worsening 
symptoms. A chest x-ray revealed a large right sided pleural effusion, she was 
treated with intravenous antibiotics and a plan was formed to move her to a 
respiratory ward to insert a chest drain. There was a delay moving Mrs Dawes 
to the respiratory ward, during that time Mrs Dawes deteriorated. She was 
transferred to the respiratory ward on 12 July 2025. A chest drain was not 
inserted and Mrs Dawes went on to suffer a cardiac arrest and died on 14 July 
2026 at Walsall Manor Hospital. 

Conclusion at inquest  

Mrs Dawes died from respiratory failure, it is unlikely that she would have died 
when she did had a chest drain been inserted during the seven days she spent 
in hospital prior to death. 

8.  CIRCUMSTANCES OF DEATH 

Mrs Dawes presented to hospital on 3 June 2025. The working diagnosis of 
the hospital at that time was Community Acquired Pneumonia, Mrs Dawes was 
discharged with antibiotics and a plan to have a repeat x-ray in six weeks time. 
The treatment received and discharge and plan formed as a result of that 
hospital attendance was appropriate.  

Mrs Dawes represented to hospital on 8 July 2025 with worsening symptoms 
including shortness of breath, lethargy and weight loss. A chest x-ray revealed 
a large right sided pleural effusion, Mrs Dawes also had raised inflammatory  
markers. She was treated with antibiotics and the plan was to move her to the 
respiratory ward where she could have a chest drain inserted.  

For reasons unknown Mrs Dawes was not moved to the respiratory ward, her 
move was delayed. She began to deteriorate, with acute kidney injury and 
deranged liver function noted before she was moved to the respiratory ward on 
Saturday 12 July 2025.  

 
 
 
 
  
 
 
 
 
 
 
 
 
 
 On 12 July 2025 Mrs Dawes was reviewed on the respiratory ward and it was 
noted that she had a raised INR level which could increase the risk of her 
bleeding during the chest drain insertion. A plan was therefore formed to give 
Mrs Dawes vitamin K to decrease her INR and to insert the chest drain after 
the weekend. Evidence was heard at inquest to confirm INR levels should 
have been checked on 8 July 2025 when the plan was initially formed to insert 
chest drains. Had that check been done, Mrs Dawes’ higher than appropriate 
INR would have been identified at that time and treated before she was moved 
to the respiratory ward, likely allowing the chest drain to be inserted on any 
date from 10 July 2025 onwards.  

During the weekend Mrs Dawes continued to deteriorate, she was reviewed on 
several occasions by resident Doctors but was not escalated up for Consultant 
input. The decision made during the weekend was that Mrs Dawes was stable 
and therefore the INR level was to be reduced with vitamin K before inserting 
the chest drain after the weekend.  

Mrs Dawes suffered a cardiac arrest on Monday 14 July 2025 and died.  

A chest drain was never inserted.  

The hospital Trust have identified learning as a result of Mrs Dawe’s death, 
however, implementation of the changes required has not been fully undertaken.  

9.  CORONER’S CONCERNS 

During the course of the inquest I heard evidence giving rise to concern. In my 
opinion there is a risk that future deaths could occur unless action is taken. In 
the circumstances it is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows: 

1.  I am concerned about the fact that the Trust accept there were missed 

opportunities and delays in the care provided to Mrs Dawes and despite 
the fact they have identified changes required to improve the care being 
delivered to their patients, those changes are yet to be implemented and 
embedded at the Trust.  

2.  The failure to take swift action to implement change undermines the 

process of identifying learning from deaths, there is little point knowing 
what needs to be done to improve patient safety if steps are not taken to 
implement those changes swiftly and effectively.  

3.  In this case we are nine months after Mrs Dawes’ death and the evidence 
heard at inquest was that it could take another three months to implement 
the changes required. I am concerned that it is going to take the Trust a 
period of twelve months to implement the changes identified as required as 
a result of Mrs Dawes’ death and the risk of future deaths continues in the 
absence of any interim measures being put in place.   

10.  COPIES AND PUBLICATION OF THIS REPORT 

I have a duty to send a copy of my report to every Interested Person who in 
my opinion should receive it. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 I also may send a copy of the report to any other person who I believe may 
find it useful or of interest. 

I can confirm I have sent the report to the family of the deceased 

I also have a duty to send a copy of the report to the Chief Coroner. 

You may make representations to me, the coroner, about the publication of the 
contents of this report in line with Chief Coroner’s PFD Publication Policy 
(2026). Any representations will be sent to the Chief Coroner alongside the 
report. Please refer to box 4 above for additional information relating to the 
publication of reports and responses. 

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