Barry Preston
4 May 2020 · Coroner Alison Mutch · Manchester; Greater Manchester South
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. incorrectly believed long term catheter
“The quality of the documentation was not always of a good standard and part of the reason why his catheter was incorrectly believed to be a long term catheter.”
2. unsuitable ward placement
“The inquest heard that he was kept on wards that were not suitable for him or his needs. The inquest was told that this was due to capacity and flow issues within the Royal Bolton Hospital.”
3. lack of care coordination
“The inquest heard that whilst he was being treated in acute settings there was no coordination or ownership of his care. It was unclear as to who was making decisions and assessing suitability of placement.”
4. unsupervised hot pudding burn
“The inquest heard that whilst an in-patient he was served a pudding that was so hot that, while eating it unsupervised, he dropped it on himself and suffered a burn. The”
5. unsuitable Laburnum Lodge placement
“His placement at Laburnum Lodge was made without a clear understanding of his needs. He fell twice within 24 hours sustaining a further bleed to his brain and readmission to the acute hospital.”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“During the time that [the deceased] was placed at the Priory the mental health trust who placed her did not have any discussion with [the deceased], her family or the Priory regarding the placement.”
This report
“The inquest heard that whilst he was being treated in acute settings there was no coordination or ownership of his care. It was unclear as to who was making decisions and assessing suitability of placement.”