“In relation to events leading up to His Honour’s death at Tra ord General Hospital on…”

The coroner’s concerns

– 1. In relation to events leading up to His Honour’s death at Tra ord General Hospital on 19th August 2025, I am concerned as to how long transpired between a family member expressing concerns about a significant change in his condition and requesting a review by a doctor, and any medical review actually taking place; 2. Having considered all of the evidence before the inquest with the utmost care, I am concerned that the approach to intentional rounding at Wythenshawe hospital in conjunction with other relevant nursing practices is insu icient to ensure vulnerable patients (such as those with cognitive impairment or the inability to eat or drink without assistance) receive adequate hydration and nutrition whilst on the wards; and 3. Whilst the Ward Manager’s local investigation in relation to the circumstances of a fall His Honour sustained on Doyle Ward, Wythenshawe hospital on 30th July 2025 has resulted in an important change in practice as regards to communication between physiotherapy and nursing professionals as to agreed sitting-out recommendations and prominent documentation of these, I am concerned that comparable measures may not be in place across the Trust as a whole.

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, 2026-0062

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