“Mr”

The coroner’s concerns

– (1) Mr. Gray’s next of kin was his daughter but he lived with his 86 year old partner. His daughter was consulted in the discharge process but the hospital did not attempt to contact his partner who was his carer. (2) Although a number of persons from di erent disciplines were involved in planning Mr. Gray’s discharge, there was no evidence of a holistic approach being taken of the discharge or in communication of the patient’s ongoing needs following discharge (3) Mr. Gray’s daughter was informed two days before the discharge that he had hyperactive delirium and that it would resolve itself but could take a few weeks. She was not made aware that Mr. Gray had at times been agitated and violent in hospital, nor was she told that although the hyperactive delirium was resolving it could fluctuate because it was likely triggered by a metabolic cause (renal function), heart failure or myocardial infarction. Neither she nor Mr. Gray’s partner were informed as to how symptoms may manifest or what to do if Mr. Gray was symptomatic. Had they known that Mr. Gray may become aggressive or violent to others particularly his carers, an early discharge would not have been encouraged

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, 2025-0579

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