Bernard Lyon
9 Apr 2025 · Coroner Alison Mutch · Manchester South
This report repeats 4 earlier warnings, and was raised again 4 times later. See the linked reports.
The coroner's concerns
1. insufficient management of care home
“The care home in question was recognised as having too few managers for it to be effectively managed but was allowed to continue to operate and was seeking to expand”
2. inadequate communication by agency staff
“The home relied on agency staff who the inquest was told struggled to have sufficient grasp of the English language to understand instructions given and to communicate with residents”
3. inadequate information flow to CQC
“the Local Authority regularly held MAC meetings to look at care home issues from a multi-agency perspective. The CQC was invited but rarely attended the meetings. As a consequence the flow of information to the CQC was reduced”
4. lack of family notification of care home concerns
“there was no process to let a family know of concerns that agencies had about a care home or that it was subject to an improvement plan. This meant that families were being left to make decisions about where to place family members unaware of the actual situation and concerns”
5. ambulance handover delays
“significant delays in the handover from the ambulance to the ED team. This was due to pressure on the ED but meant that ambulances were tied up for longer than necessary and then had a knock on impact on the ability of the ambulance service to respond to calls”
6. delayed antibiotic administration in ED
“The Emergency Department at TGH was extremely busy on the day Mr [name redacted] arrived which was not unusual. The sheer volume of patients who were seriously ill meant that there was a delay in him being given antibiotics in accordance with his need”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“The initial nurse who attended the deceased after the emergency call had poor English and needed to give evidence at the inquest through an interpreter.”
This report
“The home relied on agency staff who the inquest was told struggled to have sufficient grasp of the English language to understand instructions given and to communicate with residents.”
Identical hazardConfidence 0.90 · high
Earlier report
“Mrs [name redacted] wait of 3 hours in ED was not unusual and was due to the volume of patients waiting to be seen and the overall demand on ED.”
This report
“The Emergency Department at TGH was extremely busy on the day Mr [name redacted] arrived which was not unusual. The sheer volume of patients who were seriously ill meant that there was a delay in him being given antibiotics in accordance with his need.”
Identical hazardConfidence 0.90 · high
Earlier report
“handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital.”
This report
“significant delays in the handover from the ambulance to the ED team. This was due to pressure on the ED but meant that ambulances were tied up for longer than necessary”
Repeats an earlier warningHarry Dunn: Prevention of Future Deaths Report (1)4 Jul 2024 · 9 months earlier
Identical hazardConfidence 0.90 · high
Earlier report
“I am concerned that these continuing delays for ambulances at hospital handovers reflects a risk of deaths into the future.”
This report
“significant delays in the handover from the ambulance to the ED team. This was due to pressure on the ED but meant that ambulances were tied up for longer than necessary and then had a knock on impact on the ability of the ambulance service to respond to calls.”
Closely relatedConfidence 0.90 · high
This report
“significant delays in the handover from the ambulance to the ED team. This was due to pressure on the ED but meant that ambulances were tied up for longer than necessary and then had a knock on impact on the ability of the ambulance service to respond to calls”
Later report
“The delays getting patients from the Emergency Department (ED) into wards, causes delays taking patients from ambulances into ED, and a knock-on delay getting ambulances back out into the community. These delays persist despite the current actions to mitigate.”
Identical hazardConfidence 0.95 · high
This report
“significant delays in the handover from the ambulance to the ED team. This was due to pressure on the ED but meant that ambulances were tied up for longer than necessary and then had a knock on impact on the ability of the ambulance service to respond to calls”
Later report
“Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand.”
Closely relatedConfidence 0.80 · moderate
This report
“significant delays in the handover from the ambulance to the ED team. This was due to pressure on the ED but meant that ambulances were tied up”
Later report
“Ambulance handover delays affecting emergency availability Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available”
Closely relatedConfidence 0.92 · high
This report
“The evidence given to the inquest indicated significant delays in the handover from the ambulance to the ED team. This was due to pressure on the ED but meant that ambulances were tied up for longer than necessary and then had a knock on impact on the ability of the ambulance service to respond to calls.”
Later report
“Significant handover delays”
Responses
2025-0179-Response-from-CQC.pdf ↗· Care Quality Commission
2025-0179-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
Stated action
“the CQC is replying to you separately”
2025-0179-Response-from-Tameside-Metropolitan-Borough-Council.pdf ↗· Tameside Metropolitan Borough Council