“Mr Coulthard was assessed as being suitable for discharge on 18th December”

The coroner’s concerns

– 1. Mr Coulthard was assessed as being suitable for discharge on 18th December. He remained in an acute hospital setting for a further 4 weeks due to challenges in identifying a suitable care home. This was due the inquest was told to a shortage of suitable places and the Christmas period. The impact of this on Mr Coulthard was that he remained in an acute setting when the inquest was told the care he required would have been better delivered in a care home /nursing home setting. In addition the inquest heard evidence that it meant that an acute bed required for other patients was not available creating delays in allocating beds to patients requiring admission. The inquest was told that significant delays of this nature occur on a regular basis and are often exacerbated over the Christmas period. 2. The lack of effective communication between the discharging team and the community teams meant that it was not understood if Mr Coulthard was on End of Life Care or for rehabilitation. The staff at the first home treated him as an End of life patient / palliative care patient as a consequence even though the paperwork suggested he may be a discharge to assess patient. As a consequence he was moved to another care home for rehabilitation although the evidence was that there was little purpose in the transfer. 3. The inquest also heard evidence that the staff at the care home had queried what level and type of care was to be delivered to Mr Coulthard given his overall presentation. However there was no evidence that the management team had sought to clarify the position or ensure the internal documentation reflected the correct position. 4. The evidence before the inquest was that whilst in the community prior to his final hospital admission the access to information and support, from tissue viability and district nursing teams, to care for and treat his wounds was very limited. Better access to wound care would have reduced the risk of further wound deterioration in the community and reduced the risk of him requiring inpatient care for his wounds. However the demands across GM on TVN and DN services made this difficult to achieve.

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, 2024-0510

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