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recurance

Charlotte Jacobs

7 Nov 2019 · Coroner Rachel Galloway · Manchester City

The coroner's concerns

  1. 1. inappropriate discharge to psychiatric unit

    “The Consultant in charge of Ms [name redacted]' care (who authorised Ms [name redacted]' discharge on the 28th October 2016 to Maple Ward) indicated that - if similar circumstances arose again - he would make the same decision to transfer a patient to the Psychiatric Unit, despite the findings of the internal trust investigation that the discharge/transfer to Maple Ward should not have taken place.”
  2. 2. lack of awareness of internal investigation findings

    “The Consultant in charge of Ms [name redacted]' care and the Ward Manager for Ward 46 (at the time in 2016) did not appear to be aware of the findings of the Trust's internal investigation.”
  3. 3. absence of transfer protocol

    “Whilst I was informed that steps were being taken to put together guidance and a protocol for transfers of patients from Manchester Royal Infirmary to Park House, this had not been completed (despite Ms [name redacted]' death occurring some time ago in 2016).”

Responses

No published response was found on judiciary.uk.

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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.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error