Alan Massam
26 Apr 2021 · Coroner Alison Mutch · Manchester South
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of inter-agency information sharing
“there was no clear agreement or arrangement between agencies as to how to effectively share information in complex cases”
2. absence of national discharge protocol
“there is no national guidance/protocol about what an acute trust should do if attempts to contact a home are unsuccessful or about the obligation to ensure the home can accept him back”
3. lack of escalation process for medication refusal
“there was no defined escalation process which would ensure that the risk this presented was recognised and acted on”
4. insufficient suitable care home beds
“significant pressure to find another home that would accept him.”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“As to how that information is shared with other agencies involved in the care of that patient to ensure that it is accurately passed on, particularly as to the level of risk and degree of urgency.”
This report
“there was no clear agreement or arrangement between agencies as to how to effectively share information in complex cases”
Closely relatedConfidence 0.90 · high
This report
“there was a significant pressure to find another home that would accept him.”
Later report
“He remained in an acute hospital setting for a further 4 weeks due to challenges in identifying a suitable care home.”
Responses
2021-0120-Response-from-CQC-Redacted.pdf ↗· Department of Health and Social Care
2021-0120-Response-from-Dept-of-Health-Social-Care-Redacted.pdf ↗· Department of Health and Social Care
Stated action
“We are continuing to drive increased integration between health and social care by removing barriers to data sharing and enabling joint decision-making”
2021-0120-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership-Redacted.pdf ↗· Greater Manchester Health and Social Care Partnership and Care Quality Commission