Janet Anderson
9 May 2025 · Coroner Alison Mutch · Manchester South
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. prolonged hospital stay
“The inquest heard evidence that the prolonged hospital stay and lack of progress in finding a suitable place in the community significantly contributed to her decline”
2. poor quality documentation
“The GMMH documentation was of a poor quality and did not capture key discussions/decisions including in relation to medication”
3. acute hospital bed shortage
“The lack of progress in discharge meant that an acute hospital bed was not available to other patients who needed care in an acute setting”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“The documentation within the nursing notes, particularly the fluid charts was poor quality, making it difficult to understand what had happened in relation to the hydration of Mrs [name redacted]”
This report
“The GMMH documentation was of a poor quality and did not capture key discussions/decisions including in relation to medication.”
Closely relatedConfidence 0.90 · high
Earlier report
“During the course of the inquest the documentation relied on by the trust was lacking in detail and meant that it was difficult to understand her condition at key points or to understand the rationale for decisions.”
This report
“The GMMH documentation was of a poor quality and did not capture key discussions/decisions including in relation to medication.”