Catherine Kirkham
17 Jun 2026 · Coroner Jyoti Gill · Manchester South
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. inaccessible vaccination status information
“entries within these systems are extensive and not easily navigable, making it difficult to identify key information such as a patient's vaccination status”
2. failure to document tetanus booster administration
“treating doctor failed to record a clear clinical diagnosis and did not document the administration of a tetanus booster, despite later stating he believed it had been given”
3. oral antibiotics prescribed without swallow assessment
“prescription of oral antibiotics without conducting a swallow assessment in a patient presenting with swallowing difficulties and lockjaw”
4. missed tetanus risk identification across care points
“failures in the Urgent Treatment Centre, Emergency Department, and in the GP referral”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“there was not a joint approach to his care and no detailed discussions regarding the decision to withhold antibiotics”
This report
“prescription of oral antibiotics without conducting a swallow assessment in a patient presenting with swallowing difficulties and lockjaw”