Pamela Hindley
10 Aug 2026 · Coroner Guy Davies · Cornwall & the Isles of Scilly
This report repeats 3 earlier warnings. See the linked reports.
The coroner's concerns
1. discharged without sufficient care provision including necessary aids and adaptations to the home environment
“Rapid discharge events put significant pressure on hospital staff and community services and increases the risk of patients being discharged without sufficient care provision including necessary aids and adaptations to the home environment necessary to ensure the safety of those discharged from hospital”
2. inadequate social care provision
“The root cause of the need for the rapid discharge event was inadequate social care provision, this being an ongoing situation”
3. lack of available social care provision
“The court found significant numbers of patients in hospital who are medically fit for discharge and with no reason to reside in hospital (NCTR) but cannot be discharged due to lack of available social care provision (whether commissioned by social services or NHS)”
4. patients being cared for inside ambulances and Emergency Departments
“...there is a direct link between patients waiting in the hospital for discharge to social care and patients being cared for inside ambulances and Emergency Departments”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“The root cause for ambulance delays was found to be the lack of social care provision in Cornwall, whether care packages or beds in care homes.”
This report
“The root cause of the need for the rapid discharge event was inadequate social care provision, this being an ongoing situation.”
Identical hazardConfidence 0.95 · high
Earlier report
“Insufficient social care provision leading to large numbers of patients in hospital who are otherwise fit for discharge, thereby impeding patient flow through hospital.”
This report
“The court found significant numbers of patients in hospital who are medically fit for discharge and with no reason to reside in hospital (NCTR) but cannot be discharged due to lack of available social care provision (whether commissioned by social services or NHS).”
Identical hazardConfidence 0.90 · high
Earlier report
“Insufficient social care provision leading to large numbers of patients in hospital who are otherwise fit for discharge, thereby impeding patient flow through hospital,”
This report
“The root cause of the need for the rapid discharge event was inadequate social care provision, this being an ongoing situation.”
Responses
No published response was found on judiciary.uk.