Janice Keelan
19 Feb 2019 · Coroner Nigel Meadows · Manchester (City)
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. impaired cognition leading to inability to assess bath safety
“It must have been apparent that the deceased suffered from fluctuating and impaired cognition and probably lacked 'mental capacity' to make decisions about her own care and welfare”
2. lack of clear prioritisation process
“It was understood that there was some form of prioritisation process for dealing with these sort of cases”
3. absence of internal review
“It does not appear that following the death of the deceased, there has been any internal review or reflection by MCC about the processes involved in this case”
4. potentially avoidable death
“The death was potentially avoidable”
Linked reports
Closely relatedConfidence 0.80 · moderate
This report
“It does not appear that following the death of the deceased, there has been any internal review or reflection by MCC about the processes involved in this case”
Later report
“There were failures in the post death investigation process which may result In the true circumstances not being tdentified and steps taken to prevent continuation or recurrence of circumstances which may cause or contribute to a future death”
Responses
2019-0057-Response-by-Manchester-City-Council.pdf ↗· Manchester City Council
Stated action · 30th May 2019
“The Council has now ascertained that the deceased was not care co-ordinated by Greater Manchester Mental Health Trust (GMMH). The deceased had been cared for by a 'Lead Professional' from GMMH. This means she would be administered a depot injection every two weeks, either at home or at the depot clinic. At the Review, the Council was informed that in January, April and June 2017, her Lead Professional, asked for the deceased to be escalated to a Community Mental Health Team, as the Lead”