Mary Horgan
8 Aug 2024 · Coroner Adrian Farrow · Greater Manchester South
The coroner's concerns
1. lack of clear understanding of Patient Pass
“the obvious disparity revealed by the evidence between the two medical teams of their respective understanding and expectations of the way in which Patient Pass operates serves to create uncertainty and confusion and could easily give rise to a situation where the lives of patients may be put at risk”
2. absence of spinal precautions during transfer
“transfer of Mrs [name redacted] between hospitals without an Aspen collar and spinal precautions as advised”
3. delay in MRI scheduling
“no slot became available over the coming days”
4. inadequate procedural accommodation for mental health condition
“unable to tolerate the procedure due to claustrophobia and anxiety on a background of bipolar affective disorder”
Responses
2024-0437-Response-from-Northern-Care-Alliance.pdf ↗· Northern Care Alliance NHS Foundation Trust
Stated action · October 2024
“The Trust has convened a working group, including , Consultant [name redacted] and lead for Quality and Patient Safety from MFT to discuss how we can improve and strengthen communication between the Trusts, and to gain input and perspective from MFT as an external referrer. This group has reviewed this incident, and agreed a number of actions to both improve understanding of the Patient Pass system and improve the system itself to reduce the likelihood of recurrence of such an incident.”