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recurance

Marjorie Walker

15 Jun 2022 · Coroner Alison Mutch · Manchester South

The coroner's concerns

  1. 1. incomplete DNA CPR documentation

    “despite the consequences for a patient of a DNA CPR it had not been completed in accordance with protocols”
  2. 2. delayed specialist pain clinic access

    “significant delays in accessing specialist pain clinics due to demand and capacity issues across the NHS”
  3. 3. inadequate kidney function monitoring

    “lack of understanding and recognition of monitoring kidney function including clearance results by health professionals including pharmacists and doctors alongside prescribing created a risk of overdose particularly of vulnerable patients”

Responses

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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.

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