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recurance

Lynn Moss

4 Nov 2022 · Coroner Chris Morris · Manchester South

The coroner's concerns

  1. 1. delayed medical assessment

    “Despite the seriousness of her condition, Mrs [name redacted] waited over 5 hours from arrival at the Emergency Department until she was fully assessed by a doctor”
  2. 2. prolonged boarding time

    “Mrs [name redacted] waited for around 19 hours in the Emergency Department before a bed was to become available for her on the Acute Medical Unit”
  3. 3. missed clinical deterioration

    “Across both units, there were a number of missed opportunities to recognise a deterioration in Mrs [name redacted] condition”
  4. 4. systemic demand pressure

    “systemic problems within the health and social care sectors including difficulty in accessing primary care and delayed discharges combine to lead to persistently high levels of demand on hospital Emergency Departments”

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