Kenneth Clayton
19 Feb 2025 · Coroner Alison Mutch · Manchester South
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. prolonged wait in Emergency Department
“The inquest heard evidence that a key factor in the fall was the prolonged time Mr [name redacted] was in the Emergency Department waiting for a bed to become available on a ward”
2. prolonged wait for a bed
“example the court was told that on the morning the inquest was heard there were patients who had been waiting 40 hours for a bed on a ward.”
3. inconsistent falls risk management in Emergency Departments
“The inquest was told that for patient safety it was important, that whilst there were delays in ED throughput of patients, that a robust falls risk management system was in place”
Linked reports
Identical hazardConfidence 0.95 · high
Earlier report
“The prolonged wait Mr [name redacted] had was a result of lack of bed capacity.”
This report
“As an example the court was told that on the morning the inquest was heard there were patients who had been waiting 40 hours for a bed on a ward.”
Closely relatedConfidence 0.90 · high
Earlier report
“It was during the prolonged wait in the Emergency Department for a mental health bed that Mr [name redacted] left.”
This report
“The inquest heard evidence that a key factor in the fall was the prolonged time Mr [name redacted] was in the Emergency Department waiting for a bed to become available on a ward.”