Recurance · prevention of future deaths reports
Pre-inquest brief
Delayed referral to vascular services
The earlier warning
Michael Amesbury · 19 Jul 2023 · Alison Mutch, Manchester South
“The use of different systems and reliance on postal services and lack of a clear, effective electronic system of referrals including transfer of images /notes meant there were delays in assessing patients which led to a delay in formulating a treatment plan in tertiary services;”
judiciary.uk/…/michael-amesbury-prevention-of-future-deaths-rep…
What was promised
Stated action 1 · response to Michael Amesbury (19 Jul 2023) · stated timescale: October 2023
“We are looking at how we can bring the benefits of this type of technology to other services.”
judiciary.uk/…/2023-0259-Response-from-Greater-Manchester-Integ…
What recurred
- 13 Mar 2024 · Alan Smith · Alison Mutch · Closely related · confidence 0.86 (high)
The clearest link, quoted from both reports:
Earlier · Michael Amesbury · 19 Jul 2023
“The use of different systems and reliance on postal services and lack of a clear, effective electronic system of referrals including transfer of images /notes meant there were delays in assessing patients which led to a delay in formulating a treatment plan in tertiary services;”
Later · Alan Smith · 13 Mar 2024
“The evidence before the inquest was that there were multiple specialisms across multiple GM Trusts with different IT systems involved in Mr [name redacted] care. As a consequence communication was poor with a limited understanding of his overall condition and fragmented input.”
What happened next
No web check of the stated actions has been published for this chain.