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recurance

Mark Jones

3 Feb 2022 · Coroner Alison Mutch · Manchester South

The coroner's concerns

  1. 1. delayed referral for outpatient appointment

    “During the inquest the Court was told that there is a backlog in standard referrals such as Mr [name redacted] being seen. This means that a referral which pre Covid meant a waiting time of approximately 2.5 months for an outpatient appointment now involves a waiting time of approximately 8 months.”
  2. 2. lack of photographic evidence in referral

    “2. Mr [name redacted]' referral was sent in by his dentist to secondary care on the standard referral pathway. On receipt by the secondary care triage team the referral was assessed and based on the information provided remained on the standard referral pathway. The evidence was that a more detailed and better quality referral that included a photograph of the lesion would have probably resulted in his case being moved off the standard pathway. The inquest was told that there is no national standard or protocol”

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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