Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Joseph Cheetham · 30 Sept 2020 · Alison Mutch, Greater Manchester South
“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.”
judiciary.uk/prevention-of-future-death-reports/joseph-cheetham
What was promised
Stated action 1 · response to Joseph Cheetham (30 Sept 2020) · stated timescale: early December
“All localities within GM are now in the process of implementing these. In addition to this, further work is being undertaken to help reduce the numbers of attendances to emergency departments. As highlighted in previous correspondence, GM has agreed to a new approach which will incorporate two elements: - Implementation of the new national NHS 111 First Initiative, which will ask patients to call 111 prior to attending an Emergency Department - A new pre-Emergency Department triage and streaming”
judiciary.uk/…/2020-0189-Response-from-Greater-Manchester-Healt…
Stated action 2 · response to Joseph Cheetham (30 Sept 2020) · stated timescale: none stated
“times The Trust has in place approved policies for protecting meal times. This includes restricting visiting, visual aids to identify people who require extra support and minimising clinical interactions during meal times. Patients are regularly reviewed using the Malnutrition Universal Screening Tool (MUST) score for nutrition and hydration. We monitor nutrition and hydration through nursing quality metrics and the ward accreditation scheme. Trained volunteers also support patients with their”
judiciary.uk/…/2020-0189-Response-from-Stockport-NHS-Foundation…
What recurred
- 21 May 2021 · Martin Gibbons · Alison Mutch · Closely related · confidence 0.86 (high)
The clearest link, quoted from both reports:
Earlier · Joseph Cheetham · 30 Sept 2020
“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.”
Later · Martin Gibbons · 21 May 2021
“It was during the prolonged wait in the Emergency Department for a mental health bed that Mr [name redacted] left.”
What happened next
No evidence found either way · a stated action in a response
“This prospective single-center observational cohort study assessed older patients (≥ 65 years) using both the standard ED triage system and the ISAR scale. After a 30-day follow-up, triage levels were retrospectively adjusted upward by one level for patients with ISAR scores ≥ 2. The predictive accuracy of the revised triage system was compared to the original system using logistic regression and”
Enhancing emergency department triage for older patients: a prospective study on the integration of the identification of seniors at risk · pmc.ncbi.nlm.nih.gov/articles/PMC12135277
“🎉 KATE AI has supported over 5,000,000 patient visits, helping emergency teams deliver safer, faster, and more informed care. 🎉 [Learn more](/5-million/)”
Optimize Emergency Department Triage for Better Care | Mednition · mednition.com/…/emergency-department-triage-systems-enhance-pat…
“To ensure every ED patient gets the right care at the right time, ENA”
Triage Portfolio | ENA · ena.org/…/triage-portfolio
No evidence found does not mean the action did not happen.