“The care home in question was recognised as having too few managers for it to be…”

The coroner’s concerns

– The care home in question was recognised as having too few managers for it to be effectively managed but was allowed to continue to operate and was seeking to expand The home relied on agency staff who the inquest was told struggled to have sufficient grasp of the English language to understand instructions given and to communicate with residents. The inquest was told that the Local Authority regularly held MAC meetings to look at care home issues from a multi-agency perspective. The CQC was invited but rarely attended the meetings. As a consequence the flow of information to the CQC was reduced. The inquest was told that there was no process to let a family know of concerns that agencies had about a care home or that it was subject to an improvement plan. This meant that families were being left to make decisions about where to place family members unaware of the actual situation and concerns. The evidence given to the inquest indicated significant delays in the handover from the ambulance to the ED team. This was due to pressure on the ED but meant that ambulances were tied up for longer than necessary and then had a knock on impact on the ability of the ambulance service to respond to calls. The inquest was told that TGH had made efforts to improve the turnaround time and it was currently at just an average time of 23.22 minutes. There was further evidence that TGH were not unusual amongst hospitals in the North West with the turnaround time at other hospitals running at over 1 hour. The Emergency Department at TGH was extremely busy on the day Mr Lyon arrived which was not unusual. The sheer volume of patients who were seriously ill meant that there was a delay in him being given antibiotics in accordance with his need. The Trust had taken steps to address this but it was accepted that where there was a significant demand on an ED compliance with the national sepsis guidance was far more difficult to achieve. The inquest was told that the build-up of patients and levels of demand in the ED at TGH were not unusual and continued. As an illustration of the ongoing nature of the demand in recent months one patient has waited in ED for 3 days for a bed. The delay in transfer was due to an ongoing demand for beds and delayed discharges of patients medically optimised but with no suitable non acute/community provision being available.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2025-0179

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0