Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Thomas Barton · 21 Jul 2023 · Alison Mutch, Manchester South
“The evidence was that speedier discharges would occur if there was improved availability of social care and that this would improve outcomes for elderly patients and reduce the risk of preventable deaths occurring.”
judiciary.uk/…/thomas-barton-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Thomas Barton (21 Jul 2023) · stated timescale: none stated
“we have connected with Trafford Local Authority”
judiciary.uk/…/2023-0264-Response-from-Greater-Manchester-Integ…
Stated action 2 · response to Terence Davenport (17 Oct 2023) · stated timescale: none stated
“1. Home Finders Team (as described above) that are focussed specifically on supporting timely and appropriate placements for patients ready for discharge.”
judiciary.uk/…/2023-0389-Response-from-Greater-Manchester-Integ…
Stated action 3 · response to George Coulthard (24 Sept 2024) · stated timescale: 18 December 2023 to 11 January 2024
“the Greater Manchester NHS Foundation Trust agrees that, although it can take time to complete all the necessary arrangements for a safe and appropriate transfer of care for someone with complex needs, the time from a decision that Mr [name redacted] was medically optimised (18 December 2023) to his actual transfer to Hilltop Hall Nursing Home (11 January 2024) was too long.”
5 further stated actions are listed on the full chain page.
What recurred
- 17 Oct 2023 · Terence Davenport · Alison Mutch
- 24 Sept 2024 · George Coulthard · Alison Mutch · Identical hazard · confidence 0.92 (high)
- 10 Jul 2025 · Doreen Swann · Alison Mutch · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Terence Davenport · 17 Oct 2023
“The inquest heard evidence that the acute hospital setting was difficult for Mr [name redacted] due to his dementia and created risks to his health once he was medically optimised. He had to remain there due to a lack of suitable care/nursing beds.”
Later · George Coulthard · 24 Sept 2024
“Mr [name redacted] 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.”
What happened next
No web check of the stated actions has been published for this chain.