“The inquest heard evidence that Doreen Swann was only in hospital at the point of her…”
Dated 10 Jul 2025, from the coroner for Manchester South. Sent to 2 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 Sep 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 dated10 Jul 2025
- Deadline4 Sep 2025
- Published on judiciary.uk17 Jul 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Department of Health and Social CareNamed in the report as “The Department of Health and Social Care” | Response publishedPublished on judiciary.uk in July 2025. |
| NHS Greater Manchester Integrated Care BoardNamed in the report as “Greater Manchester Integrated Care” | Response publishedPublished on judiciary.uk in July 2025. |
The coroner’s concerns
– 1. The inquest heard evidence that Doreen Swann was only in hospital at the point of her fall because her discharge had been delayed due to a shortage of a suitable social care placement. The evidence was that nursing/caring for high falls risk patients in an acute setting is challenging and resource intensive. 2. The evidence given to the inquest was that this delayed discharge and the ongoing risk it presents was not an isolated incident at TGH -as an example the evidence given was that there were regularly 30 plus patients with a 1 delayed discharge over 3 weeks due to a lack of social care beds .The evidence indicated that this challenge was not unique to Tameside. 3. The evidence indicated that managing a falls risk and the consequential risk to life is better managed outside an acute setting once the clinical need for a hospital stay has passed. 4. Delayed discharges such as Doreen Swann’s reduces the availability of beds for other patients and creates a knock-on impact across the hospital particularly in relation to the Emergency Department.
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, 2025-0359
- Added to Minute Book
- 8 Oct 2026
- Reuse
- 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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