Doreen Swann
10 Jul 2025 · Coroner Alison Mutch · Manchester South
This report repeats 3 earlier warnings. See the linked reports.
The coroner's concerns
1. high falls risk patients in acute setting
“The evidence was that nursing/caring for high falls risk patients in an acute setting is challenging and resource intensive”
2. delayed discharge creates knock-on impact across hospital
“and creates a knock-on impact across the hospital particularly in relation to the Emergency Department.”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“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.”
This report
“Delayed discharges such as [the deceased]'s reduces the availability of beds for other patients and creates a knock-on impact across the hospital particularly in relation to the Emergency Department.”
Identical hazardConfidence 0.90 · high
Earlier report
“He had to remain there due to a lack of suitable care/nursing beds. This meant that he was in an unsuitable care setting and that a bed that could have been utilised for an acute patient was not available;”
This report
“The inquest heard evidence that [the deceased] was only in hospital at the point of her fall because her discharge had been delayed due to a shortage of a suitable social care placement.”
Identical hazardConfidence 0.90 · high
Earlier report
“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.”
This report
“The inquest heard evidence that [the deceased] was only in hospital at the point of her fall because her discharge had been delayed due to a shortage of a suitable social care placement.”