Michael Amesbury
19 Jul 2023 · Coroner Alison Mutch · Manchester South
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. delays in referral assessment
“The use of different systems and reliance on postal services and lack of a clear, effective electronic system of referrals including transfer of images /notes meant there were delays in assessing patients which led to a delay in formulating a treatment plan in tertiary services”
2. delays in cardiology clinic access
“delays in patients who had been identified as requiring cardiology input being seen in cardiology clinics due to availability of clinicians/appointment slots inquest”
3. lack of trans-oesophageal echocardiogram availability
“The inquest heard that this type of echocardiogram could be key in understanding the cardiac issues of a patient”
Linked reports
Closely relatedConfidence 0.86 · high
This report
“The use of different systems and reliance on postal services and lack of a clear, effective electronic system of referrals including transfer of images /notes meant there were delays in assessing patients which led to a delay in formulating a treatment plan in tertiary services;”
Later report
“The evidence before the inquest was that there were multiple specialisms across multiple GM Trusts with different IT systems involved in Mr [name redacted] care. As a consequence communication was poor with a limited understanding of his overall condition and fragmented input.”
Closely relatedConfidence 0.85 · high
This report
“The use of different systems and reliance on postal services and lack of a clear, effective electronic system of referrals including transfer of images /notes meant there were delays in assessing patients”
Later report
“significant wait times for essential tests such as trans oesophageal echocardiograms to be carried out due to a shortage of suitably quailed professionals”
Responses
2023-0259-Response-from-Greater-Manchester-Integrated-Care.pdf ↗· Greater Manchester Integrated Care
Stated action · October 2023
“We are looking at how we can bring the benefits of this type of technology to other services.”