“There was no process in place for risk assessment plans to be completed when a resident's…”
Dated 26 Apr 2017, from the coroner for Manchester South. Sent to 1 organisation or person.
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 publishedOrganisations 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 dated26 Apr 2017
- Deadline21 Jun 2017
- Published on judiciary.uk10 Jul 2017
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Stockport NHS Foundation Trust | Response publishedPublished on judiciary.uk in July 2017. |
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The coroner’s concerns
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— 1. There was no process in place for risk assessment plans to be completed when a resident's needs changed from care to nursing needs and a bed was awaited. 2. The District Nursing Team were unaware of the change in status and there was no system in place to involve them in discussions. Patient records completed by the District Nursing Team lacked detail and were not completed in the required timescales. There was no continuity of care provided by the District Nursing Team. There was little evidence of communication and information sharing between the care home and the District Nursing Team The Care Home notes were lacking in detail A suitable nursing home placement could not be identified once it had been agreed that the Care Home was no longer the best place to meet the needs of Mr Davies 8. Advice was not sought by the District Nurses when they had difficulties examining Mr Davies e NO ge 9. The correct procedure was not followed on previous occasions when a trigger point was reached in relation to pressure relieving strategies.
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, 2017-0138
- 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
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