Edith Jones
15 May 2026 · Coroner Alison Mutch · Manchester South
The coroner's concerns
1. poor documentation
“The quality of the District Nursing team documentation was poor. Consequently, it was diƯicult to understand the steps taken and the rationale for actions”
2. lack of oversight
“There was little evidence of oversight by District Nursing Team managers of how complex cases such as Mrs [name redacted] were being managed”
3. no prompt escalation
“There was no prompt escalation of her case by the District Nurses when the situation deteriorated”
4. ineffective triage process
“The District Nursing gateway referral system had a triage process that did not identify or manage proactively her deteriorating condition”
5. ineffective triage system
“The GP practice did not have an eƯective system to promptly triage referrals from the 111 service or information provided by a patients family”