Alan Smith
13 Mar 2024 · Coroner Alison Mutch · Manchester South
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. delayed referral to vascular services
“prompt referral to vascular services was important in cases such as these”
Linked reports
Closely relatedConfidence 0.86 · high
Earlier report
“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;”
This report
“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.”