Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Reginald Collins · 30 Jul 2020 · Alison Mutch, Manchester South
“The inquest heard that Mr [name redacted] could have been discharged from 19th September when he was medically optimised. However he remained in an acute hospital setting until his death on 22nd 1 October because of the challenges of finding a suitable EMI placement for him.”
judiciary.uk/prevention-of-future-death-reports/reginald-collins
What was promised
Stated action 1 · response to Reginald Collins (30 Jul 2020) · stated timescale: none stated
“a GM Discharge Pathway and good Discharge to Assess (D2A) system in place”
judiciary.uk/…/2020-0146-Response-from-Greater-Manchester-Combi…
Stated action 2 · response to Alan Massam (26 Apr 2021) · stated timescale: none stated
“We are continuing to drive increased integration between health and social care by removing barriers to data sharing and enabling joint decision-making”
judiciary.uk/…/2021-0120-Response-from-Dept-of-Health-Social-Ca…
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.”
What recurred
- 26 Apr 2021 · Alan Massam · Alison Mutch
- 24 Sept 2024 · George Coulthard · Alison Mutch · Closely related · confidence 0.90 (high)
- 7 May 2026 · Elsie Jones · Louise Hunt · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Reginald Collins · 30 Jul 2020
“The inquest heard that Mr [name redacted] could have been discharged from 19th September when he was medically optimised. However he remained in an acute hospital setting until his death on 22nd 1 October because of the challenges of finding a suitable EMI placement for him.”
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.