John Cheetham
13 Jul 2020 · Coroner Alison Mutch · Greater Manchester South
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. risk of falls in Emergency Department
“The inquest heard that since the events leading up to Mr [name redacted] death the Trust has taken steps to reduce the risk of falls in the Emergency Department”
2. ED capacity issues
“The evidence given to the inquest was that the Trust and all I other acute hospitals in Greater Manchester were at that time facing significant challenges in terms of ED capacity”
3. lack of bed capacity
“The prolonged wait Mr [name redacted] had was a result of lack of bed capacity”
4. shortage of ED trained nurses
“The inquest was also told that a shortage of nurses nationally trained to work in ED had meant that the unit was short staffed on the night he fell”
5. risk assessment not performed early
“In his case a risk assessment was not carried out at the earliest opportunity”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“The prolonged wait Mr [name redacted] had was a result of lack of bed capacity.”
Later report
“bed capacity remains an ongoing problem and has not been resolved.”
Identical hazardConfidence 0.95 · high
This report
“The prolonged wait Mr [name redacted] had was a result of lack of bed capacity.”
Later 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.”
Responses
2020-0140-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership_Redcated.pdf ↗· Greater Manchester Health and Social Care Partnership
Stated action · April 2022
“To reduce attendances to Emergency Departments (ED) by improving access to, and utilisation of, primary and community-based services by rapidly developing and testing a GM 'UEC by Appointment' model”
Stated action · April 2022
“By April 2022, we will reduce: - Ambulance attendances by 100 per day across GM - ED walk in attendances by 300 per day across GM”
Stated action · September and October this year (ahead of winter)
“The new approach will incorporate two elements: - Implementation of the new national NHS 111 First Initiative, which will ask patients to call 111 prior to attending an Emergency Department - A new pre-Emergency Department triage and streaming system”
Stated action
“The hub also supports the management of discharges from hospital and repatriations between hospital sites (in and out of the GM area). The hub is under constant development and is working closely with systems to develop more sophisticated methods of managing demand to reduce the likelihood of emergency department crowding even further and proactively managing flow to prevent blockages”
Stated action · late April (formally approved)
“Adoption of a single GM Discharge to Assess Referral Form - Triage of discharge to assess referrals within 30mins - Adherence to the guidance for COVID 19 testing for discharge and PPE requirements - The supply of 2 weeks medication supplies at the point of discharge from an acute hospital - Operation of a next day follow up process following discharge (localities to determine how this is delivered)”
Stated action
“Nurse recruitment and retention is a priority for the Greater Manchester system and work is underway with Greater Manchester service colleagues, NHSE/I and Health Education England, in order to maximise opportunities for improved nurse staffing in all localities”
2020-0140-Response-from-the-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
Stated action · January and February this year
“My officials have made enquiries with the Care Quality Commission (CQC), the independent regulator of quality, and NHS England and NHS Improvement (NHSEl) and | am aware that regulatory action was taken by the CQC following an inspection at Stepping Hill Hospital in January and February this year”