Martin Gibbons
21 May 2021 · Coroner Alison Mutch · Manchester South
This report repeats 1 earlier warning, and was raised again 3 times later. See the linked reports.
The coroner's concerns
1. lack of shared definition of high risk patient
“During the course of the inquest evidence was heard that the acute and mental health trusts involved had assessed the level of risk he presented differently in part due to there being no shared definition of risk or the factors that triggered a patient being treated as high risk”
2. absence of shared risk assessments and care plans
“The inquest heard evidence that since Mr [name redacted] death both trusts had recognised that to reduce risk there needed to be detailed and documented shared risk assessments and care plans for patients such as him in an acute setting”
3. prolonged wait for mental health bed
“It was during the prolonged wait in the Emergency Department for a mental health bed that Mr [name redacted] left”
Linked reports
Closely relatedConfidence 0.86 · high
Earlier report
“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.”
This report
“It was during the prolonged wait in the Emergency Department for a mental health bed that Mr [name redacted] left.”
Identical hazardConfidence 0.90 · high
This report
“It was during the prolonged wait in the Emergency Department for a mental health bed that Mr [name redacted] left”
Later report
“The inquest heard that [the deceased] was kept in an acute hospital setting at Salford Royal Hospital awaiting a mental health bed due to a shortage of mental 2 health beds”
Identical hazardConfidence 0.90 · high
This report
“It was during the prolonged wait in the Emergency Department for a mental health bed that Mr [name redacted] left.”
Later report
“The Matron in Acute and Urgent Care confirmed bed capacity remains an ongoing problem and has not been resolved.”
Closely relatedConfidence 0.90 · high
This report
“It was during the prolonged wait in the Emergency Department for a mental health bed that Mr [name redacted] left.”
Later 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.”
Responses
2021-0166-Response-from-Department-of-Health-Social-Care_Published.pdf ↗· Department of Health and Social Care
Stated action
“Recently, (and in part due to concerns raised by your report) NHS England has asked all parts of the country to ensure that they have in place clear written protocols for escalation and actions to be taken when patients are waiting long periods, or a bed cannot be identified.”
2021-0166-Response-from-GMCA_Published.pdf ↗· Department of Health and Social Care
Stated action
“The LMHT has now completed a joint piece of work with their ED colleagues at TGICFT. A triage assessment tool has been implemented which guides the triage nurse to consider the most appropriate pathway for the patient based on their risk/presentation at that time.”