Lorraine Julia Proctor · Prevention of Future Deaths report

On 27th December 2023 I commenced an investigation into the death of Lorraine Julia PROCTOR. The investigation concluded on the 25th 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 2nd 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 as found unresponsive in bed at her home address ████████. A post-mortem established that the direct cause of her death was 1A) Acute myocardial ischaemia 1b) Coronary artery atheroma 1c) Ischaemic cardiomyopathy.

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.