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recurance

Anne Taylor

8 Nov 2024 · Coroner Michael Pemberton · Manchester (West)

The coroner's concerns

  1. 1. leaving hospital before clinical assessment

    “the deceased had elected to leave the Hospital on Friday 19 July because of waiting times, before being clinically assessed”
  2. 2. lack of secondary investigations

    “no consideration of whether secondary investigations could be undertaken during the waiting time for example CT scan which would likely be required by a clinician in order to make a diagnosis”
  3. 3. capacity assessment not performed

    “No evidence was provided that the deceased's capacity to decide to leave the hospital was assessed given the history of suspected head injury.”
  4. 4. unclear SOP for leaving hospital

    “a new standard operating procedure being developed relating to patients leaving the hospital before a clinical assessment occurs, but it was unclear what this will include”

Responses

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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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