Margaret Murphy
21 Jul 2026 · Coroner Chris Morris · Greater Manchester (South)
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. national shortage of medical microbiology doctors
“A consultant in medical microbiology gave evidence as to a national shortage of doctors of that specialism in the NHS. Given the significance of microbiology to modern medicine, I am concerned any such shortage creates a risk of future deaths”
2. off-site laboratory processing of microbiology tests
“The court heard evidence that Tameside Hospital relies on an off-site laboratory to undertake and report on microbiology tests such as blood-cultures. Whilst not a relevant factor in Miss [name redacted] case, I am concerned as to the impact this system has for the time it takes relevant results to reach treating clinicians”
3. disjointed clinical information system
“Having reviewed Miss [name redacted] in the Same Day Emergency Care Unit on 5 October 2025, the Orthopaedic Senior House Officer wrote their notes in a Trauma and Orthopaedic 'Tracker', not routinely accessible to clinicians working in other specialities. I am concerned as to the risk of future deaths which arises from the creation of an extra layer of documentation not easily visible to others in the hospital, particularly in the context of an already disjointed and labyrinthine system for capturing clinical information”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“over the course of almost 10 hours in hospital, [the deceased]'s history and details of examinations and assessments undertaken were recorded on a mixture of various analogue and digital systems in operation in different parts of the Trust, leading to a risk of vital clinical information being lost in the system.”
This report
“Having reviewed Miss [name redacted] in the Same Day Emergency Care Unit on 5 October 2025, the Orthopaedic Senior House Officer wrote their notes in a Trauma and Orthopaedic 'Tracker', not routinely accessible to clinicians working in other specialities.”