“The inquest heard that his GP had sought to have him admitted directly into hospital…”
Dated 30 Sep 2020, from the coroner for Manchester South. Sent to 3 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 25 Nov 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 dated30 Sep 2020
- Deadline25 Nov 2020
- Published on judiciary.uk23 Nov 2020
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Department of Health and Social Care | 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. |
| Greater Manchester Health & Social Care Partnership | Response publishedPublished on judiciary.uk in June 2022. |
| Health Services Safety Investigations BodyNamed in the report as “The Healthcare Safety Investigation Branch” | 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. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
1. The inquest heard that his GP had sought to have him admitted directly into hospital having identified that he needed to be hospitalised. However, contact with the trust identified that the acute bed shortage meant that this would not be possible, and he would have to go via A and E. On arrival at A and E the volume of those waiting to be seen meant that he waited in cold and draughty areas of the department Lack of bed capacity in the hospital meant that he spent over 24 hours in the A and E department despite being frail and vulnerable. 2. The inquest heard that he was medically optimised, and he had lost weight in hospital whilst awaiting a care package to be put in place. One was still not in place by 24th December and it was likely to be at least another 2-3 weeks before one was in place. To avoid further deconditioning and weight loss in an acute setting whilst awaiting a care package his family took on caring for him at home to facilitate a discharge.
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, 2020-0189
- 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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