“The quality of the documentation was not always of a good standard and part of the reason…”
Dated 4 May 2020, from the coroner for Manchester South. Sent to 4 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
Deadline passedReplies were due by 29 Jun 2020. A reply may have been sent and not yet published.
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.
- Report dated4 May 2020
- Deadline29 Jun 2020
- Published on judiciary.uk9 Jun 2020
- Today27 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Greater Manchester Mental Health NHS Foundation TrustNamed in the report as “Greater Manchester Mental Health NHS Foundation Trust (GMMH)” | Response publishedPublished on judiciary.uk in June 2022. |
| Bolton Council | Response publishedPublished on judiciary.uk in June 2022. |
| Royal Bolton Hospital | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Department of Health and Social CareNamed in the report as “Department for Health and Social Care” | Response publishedPublished on judiciary.uk in June 2022. |
The coroner’s concerns
– 1. The quality of the documentation was not always of a good standard and part of the reason why his catheter was incorrectly believed to be a long term catheter. 2. The inquest heard that he was kept on wards that were not suitable for him or his needs. The inquest was told that this was due to capacity and flow issues within the Royal Bolton Hospital. 3. The inquest heard that he had a care coordinator in the community. However the care coordinator did not take a lead in ensuring he was being supported in the acute settings or that best interests meetings were taking place. There was a lack of understanding between agencies of roles and responsibilities under the integrated care model. 4. The inquest heard that whilst he was being treated in acute settings there was no coordination or ownership of his care. It was unclear as to who was making decisions and assessing suitability of placement. 5. The inquest was told that for a long period of time whilst in the care of the NHS there was not a clear understanding of his lack of capacity to make decisions about his care. Acquiescence by him was seen as him understanding and having capacity. 6. The inquest heard that whilst an in-patient he was served a pudding that was so hot that, while eating it unsupervised, he dropped it on himself and suffered a burn. The burn did not contribute to his death but did cause significant additional discomfort. 7. His placement at Laburnum Lodge was made without a clear understanding of his needs. He fell twice within 24 hours sustaining a further bleed to his brain and readmission to the acute hospital.
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, 2020-0110
- 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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