Lorraine Procter

I am Alison Mutch, Senior Coroner, for the coroner area of South Manchester

On 27 th December 2023 I commenced an investigation into the death of  Lorraine Julia PROCTER. The investigation concluded on the 25 th June  2024 and the conclusion was one of natural causes. The medical cause of death was 1a) Acute myocardial ischaemia 1b) Coronary artery  atheroma 1c) Ischaemic cardiomyopathy II, Type 2 diabetes mellitus,  chronic obstructive pulmonary disease, sleep apnoea.

Lorraine Julia Proctor had a history of cardiac health issues. She was  discharged from hospital on 2 nd March 2023 with an indication she should have a cardiology follow up appointment 3 months later. The appointment should have been in June 2023.It did not take place as the waiting list for routine cardiology appointments was 48 weeks. The inquest was told it  was unlikely the appointment had it taken place would have changed the  treatment she was on. On 22nd December 2023, Lorraine Julia Proctor was found unresponsive in bed at her home address [REDACTED]. A post-mortem established that the direct cause of her death was 1a) Acute myocardial ischaemia 1b ) Coronary artery atheroma 1c) Ischaemic  cardiomyopathy.

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur  unless action is taken. In the circumstances it is my statutory duty to  report to you. The MATTERS OF CONCERN are as follows.  – The inquest was told that there are significant backlogs for cardiology  appointments not just in Greater Manchester but nationally. The reasons  the inquest was told were multi factorial and included demand, resources available, covid backlogs and the impact of strike action. As a consequence patients referred for first cardiology appointments  from primary care are often waiting in excess of 40 weeks for a first  specialist appointment and existing cardiology patients are also waiting  similar periods of time for follow up appointments. In Ms Proctor’s case the inquest was told that it was unlikely that there  would have been a change to the treatment she was on even if she had  been seen. However it was clear that this would not always be the case  and patients requiring specialist input were not receiving it within the  timescales that reduced the risk of complications and death.

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.