“The inquest heard evidence that the prolonged hospital stay and lack of progress in…”
Dated 9 May 2025, from the coroner for Manchester South. Sent to 3 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 4 Jul 2025.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated9 May 2025
- Deadline4 Jul 2025
- Published on judiciary.uk20 May 2025
- Today27 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Manchester University NHS Foundation Trust | Response publishedPublished on judiciary.uk in May 2025. |
| Greater Manchester Mental Health NHS Foundation TrustNamed in the report as “Greater Manchester Mental Health” | Response publishedPublished on judiciary.uk in May 2025. |
| NHS Greater Manchester Integrated Care BoardNamed in the report as “Greater Manchester Integrated Care Board” | Response publishedPublished on judiciary.uk in May 2025. |
The coroner’s concerns
– 1. The inquest heard evidence that the prolonged hospital stay and lack of progress in finding a suitable place in the community significantly contributed to her decline. She had been suitable for discharge from 20 th May and there was no clear strategy to progress her discharge or for the two different trusts to work together to ensure a speedy and safe discharge. The evidence before the inquest indicated a lack of joined up working between the two trusts that meant that despite the clinical concerns about the impact of her prolonged hospital stay she remained in an acute setting 2. The GMMH documentation was of a poor quality and did not capture key discussions/decisions including in relation to medication. As a consequence, trust staff were not fully sighted on earlier decisions and her needs. 3. The lack of progress in discharge meant that an acute hospital bed was not available to other patients who needed care in an acute setting.
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, 2025-0219
- Added to Minute Book
- 8 Oct 2026
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- We show short extracts and link to the original. We don’t host the full report.
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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
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