12 Oct 2023 David Hall · Prevention of Future Deaths report Manchester South
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Concerns raised 1 Lack of availability of suitable emergency social care placements within Stockport View source
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
David Hall · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Hall, who had dementia, was admitted to hospital because no safe and suitable social care placement was available and later remained there while awaiting placement. His nutritional needs were not fully met, his swallow deteriorated, and he developed aspiration pneumonia; he also contracted COVID-19 and died in hospital. The principal concern was the shortage of suitable social care placements, which contributed to his hospital admission and delayed discharge.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to One Stockport Health and Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of availability of suitable emergency social care placements within Stockport
Wider context from the report “The inquest heard evidence that if a suitable emergency social care placement had been available then Mr Hall would not have been admitted to hospital. However, there was no alternative as one could not be found and he was unsafe in the community. His stay in the acute setting led to a rapid deterioration. He had to continue to stay in hospital because a suitable social care placement could not be found for him . The evidence was that had he been in a suitable social care setting his needs would have been met in a more appropriate way.
The evidence was that these difficulties in finding a placement were as a result of issues in availability of social care within Stockport .
” Open source report
9 Oct 2023 Mark Anthony McKessy · Prevention of Future Deaths report Manchester South
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Concerns raised 3 Poor communication and information sharing between agencies View source Lack of recognition of the interrelationship between health, social care, learning disability and capacity needs View source Limited Care Act assessments View source
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 5
Action
Introduce peer discussions so managers oversee individual social-care assessments and reviews and strengthen social-work practice.
View source
Action
Hold a joint learning event involving agencies supporting people with learning disabilities to strengthen information sharing and practice.
View source
Action
Review the health and social-care offer, including assessment, advice, signposting, substance-misuse support, information and staff training needs, through standing quality-meeting consideration.
View source
Action
Improve frontline knowledge and confidence in completing holistic social-care assessments.
View source
Action
Agree a joint action plan following the learning event to improve information sharing and practice.
View source See 2 more actions
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AI-generated summary
Mark Anthony McKessy · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mark Anthony McKessy had learning disabilities and care needs and developed alcoholic liver disease following regular and prolonged alcohol use. He deteriorated after admission to Stepping Hill Hospital and died there on 18 February 2023. The principal concerns were poor communication and information sharing between agencies, lack of coordinated care, and insufficient recognition of how his health, social care and learning disability needs interacted, including the extent of his capacity.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to One Stockport Health and Care Board; that does not assign responsibility.
PFD Monitor interpretation Poor communication and information sharing between agencies
Wider context from the report “The inquest heard evidence that he had significant leaning difficulties and his capacity was limited. He was known to agencies. Despite this the inquest heard evidence that steps to reduce the risks were not taken due to:
1. Poor communication/information sharing between agencies which meant that there was no coordination of care and no clear overview of his needs ; and
2. A lack of recognition by agencies involved with him of his health issues and their inter relationship with his social care and learning disability needs including the extent to which he had capacity. This was compounded by limited Care Act assessments
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to One Stockport Health and Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of recognition of the interrelationship between health, social care, learning disability and capacity needs
Wider context from the report “The inquest heard evidence that he had significant leaning difficulties and his capacity was limited. He was known to agencies. Despite this the inquest heard evidence that steps to reduce the risks were not taken due to:
1. Poor communication/information sharing between agencies which meant that there was no coordination of care and no clear overview of his needs; and
2. A lack of recognition by agencies involved with him of his health issues and their inter relationship with his social care and learning disability needs including the extent to which he had capacity . This was compounded by limited Care Act assessments
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to One Stockport Health and Care Board; that does not assign responsibility.
PFD Monitor interpretation Limited Care Act assessments
Wider context from the report “The inquest heard evidence that he had significant leaning difficulties and his capacity was limited. He was known to agencies. Despite this the inquest heard evidence that steps to reduce the risks were not taken due to:
1. Poor communication/information sharing between agencies which meant that there was no coordination of care and no clear overview of his needs; and
2. A lack of recognition by agencies involved with him of his health issues and their inter relationship with his social care and learning disability needs including the extent to which he had capacity. This was compounded by limited Care Act assessments
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce peer discussions so managers oversee individual social-care assessments and reviews and strengthen social-work practice.
Verbatim wording from the response “We continue to improve front line practice to ensure our frontline teams increase their knowledge and confidence in completing holistic assessments. To ensure management oversee individual assessments and reviews we are introducing peer discussions to strengthen social work practice. The social care and specialist learning disability health team are co-located to support a joined-up approach to interventions. This is further supported by managers across social care and health meeting on a weekly basis, using the forum to refer individuals for a multi-disciplinary and multi-agency approach.” Source location Response from Stockport Integrated Care Partnership
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold a joint learning event involving agencies supporting people with learning disabilities to strengthen information sharing and practice.
Verbatim wording from the response “There will be a joint learning event in January 2024 in relation to Mr McKessy’s life and death. All the agencies involved in supporting people with a learning disability in Stockport will be in attendance and agree a joint action plan to further strengthen information sharing and improvements to practice. We will also liaise with Mr McKessy’s family, if they wish to be involved, to share their experiences of the health and social care” Source location Response from Stockport Integrated Care Partnership
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the health and social-care offer, including assessment, advice, signposting, substance-misuse support, information and staff training needs, through standing quality-meeting consideration.
Verbatim wording from the response “Following Mr McKessy’s passing, analysis of our current offer, from both social care and health is being considered, including how we carry out assessments, provide advice, our signposting for individuals and our support provided people who experience any element of substance mis-use. This will be a standing agenda at the PCFT Quality Meetings; this will support consideration to further information or training for staff is required, whether we have appropriate information and resources to share with individuals and/or their carers.” Source location Response from Stockport Integrated Care Partnership
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve frontline knowledge and confidence in completing holistic social-care assessments.
Verbatim wording from the response “We recognise there were missed opportunities at this time to fully understand his situation and the impact of drinking on his health and social care needs.” Source location Response from Stockport Integrated Care Partnership
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Agree a joint action plan following the learning event to improve information sharing and practice.
Verbatim wording from the response “There will be a joint learning event in January 2024 in relation to Mr McKessy’s life and death. All the agencies involved in supporting people with a learning disability in Stockport will be in attendance and agree a joint action plan to further strengthen information sharing and improvements to practice. We will also liaise with Mr McKessy’s family, if they wish to be involved, to share their experiences of the health and social care” Source location Response from Stockport Integrated Care Partnership
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Pennine Care NHS Foundation Trust cannot directly access patients’ full clinical histories through current systems.
Verbatim wording from the response “All Stockport GPs use the Emis Clinical system, including our community and out of hours services. This means that community and out of hours services directly accessing individual patient clinical records. At the current time, Pennine Care NHS Foundation Trust cannot directly access a patient’s full clinical history. I can confirm that there is ongoing work within Greater Manchester to extend sharing of information across healthcare services.” Source location Response from Stockport Integrated Care Partnership
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations