“The inquest heard that the quality of the documentation relating to Mr Hunter was poor…”
Dated 25 Oct 2021, 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 publishedReplies were due by 20 Dec 2021.
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; a reply may have been sent and not yet published.
- Report dated25 Oct 2021
- Deadline20 Dec 2021
- Published on judiciary.uk4 Nov 2021
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Stockport NHS Foundation TrustNamed in the report as “Stockport NHS Trust” | Response publishedPublished on judiciary.uk in November 2021. |
The coroner’s concerns
– The inquest heard that the quality of the documentation relating to Mr Hunter was poor particularly in relation to monitoring his diet and weight. The BMI was incorrectly calculated on admission and this was not identified subsequently. As a consequence his MUST score was inaccurate and his level of risk due to his weight and poor nutritional status was not correctly understood. The NICE guidance relating to monitoring weight was not followed and this was not recognised by ward managers.
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, 2021-0369
- 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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