9 Apr 2025 Bernard Lyon · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 8 Lack of a process to inform families about care home concerns and improvement plans View source Failure of CQC participation in multi-agency care home oversight meetings View source Delays in ambulance handover to the emergency department View source Delays in providing antibiotics in accordance with sepsis needs during high emergency-department demand View source Failure of agency staff to communicate effectively in English with residents and colleagues View source Lack of suitable non-acute or community provision for medically optimised patients View source Lack of sufficient management capacity in the care home View source Insufficient emergency-department bed capacity causing delays in patient transfer View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Bernard Lyon · 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
Bernard Lyon, who had dysphagia and was living at Hyde Nursing Home, developed sepsis and aspiration pneumonia and died at Tameside General Hospital on 30 January 2024. The report describes concerns about the nursing home's management capacity, staffing and adherence to his modified diet plan, as well as multi-agency oversight, communication with families, ambulance handover delays and delays in administering antibiotics in a very busy emergency department.
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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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a process to inform families about care home concerns and improvement plans
Wider context from the report “4. The inquest was told that there was no process to let a family know of concerns that agencies had about a care home or that it was subject to an improvement plan . This meant that families were being left to make decisions about where to place family members unaware of the actual situation and concerns.
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure of CQC participation in multi-agency care home oversight meetings
Wider context from the report “3. The inquest was told that the Local Authority regularly held MAC meetings to look at care home issues from a multi-agency perspective. The CQC was invited but rarely attended the meetings . As a consequence, the flow of information to the CQC was reduced .
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance handover to the emergency department
Wider context from the report “5. The evidence given to the inquest indicated significant delays in the handover from the ambulance to the ED team . This was due to pressure on the ED but meant that ambulances were tied up for longer than necessary and then had a knock-on impact on the ability of the ambulance service to respond to calls. The inquest was told that TGH had made efforts to improve the turnaround time, and it was currently at just an average time of 23.22 minutes. There was further evidence that TGH were not unusual amongst hospitals in the Northwest with the turnaround time at other hospitals running at over 1 hour.
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Delays in providing antibiotics in accordance with sepsis needs during high emergency-department demand
Wider context from the report “6. The Emergency Department at TGH was extremely busy on the day Mr Lyon arrived which was not unusual. The sheer volume of patients who were seriously ill meant that there was a delay in him being given antibiotics in accordance with his need . The Trust had taken steps to address this, but it was accepted that where there was a significant demand on an ED compliance with the national sepsis guidance was far more difficult to achieve .
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure of agency staff to communicate effectively in English with residents and colleagues
Wider context from the report “2. The home relied on agency staff who the inquest was told struggled to have sufficient grasp of the English language to understand instructions given and to communicate with residents .
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of suitable non-acute or community provision for medically optimised patients
Wider context from the report “7. The inquest was told that the build-up of patients and levels of demand in the ED at TGH were not unusual and continued. As an illustration of the ongoing nature of the demand in recent months one patient has waited in ED for 3 days for a bed. The delay in transfer was due to an ongoing demand for beds and delayed discharges of patients medically optimised but with no suitable non acute/community provision being available .
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of sufficient management capacity in the care home
Wider context from the report “1. The care home in question was recognised as having too few managers for it to be effectively managed but was allowed to continue to operate and was seeking to expand
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient emergency-department bed capacity causing delays in patient transfer
Wider context from the report “7. The inquest was told that the build-up of patients and levels of demand in the ED at TGH were not unusual and continued. As an illustration of the ongoing nature of the demand in recent months one patient has waited in ED for 3 days for a bed. The delay in transfer was due to an ongoing demand for beds and delayed discharges of patients medically optimised but with no suitable non acute/community provision being available.
” 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 Implement more robust contract monitoring processes and quality visits across care homes.
Verbatim wording from the response “We have undertaken a review of the Commissioning Team structure and increased the number of quality monitoring officers. We are implementing more robust contract monitoring processes and quality visits to ensure we are working with all the homes more closely. This will identify any issues that may arise in relation to staffing, recruitment and language barriers.” Source location Response from Tameside Metropolitan Borough Council
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 Launch the revised Multi Agency Concern guidance with providers after governance sign-off.
Verbatim wording from the response “We have revised our Multi Agency Concern (MAC) process to stipulate that providers are notifying families where there are concerns within the home. We will be launching the guidance with providers in the coming months, following sign off through our governance process. In the meantime, the MAC meetings stress the importance of notifying families where there are any concerns within homes that are subject to the MAC process.” Source location Response from Tameside Metropolitan Borough Council
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 Revise the Multi Agency Concern process to require providers to notify families about concerns in care homes.
Verbatim wording from the response “We have revised our Multi Agency Concern (MAC) process to stipulate that providers are notifying families where there are concerns within the home. We will be launching the guidance with providers in the coming months, following sign off through our governance process. In the meantime, the MAC meetings stress the importance of notifying families where there are any concerns within homes that are subject to the MAC process.” Source location Response from Tameside Metropolitan Borough Council
Open published response
16 Sep 2021 Irene Ann Esaw · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure to complete adequate assessments of patients’ needs View source Failure to clarify multi-agency responsibility for capacity and needs assessments View source Failure to adequately assess patients’ mental capacity for care decisions View source Failure to recognise clinical indicators of neglect as safeguarding concerns View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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
Update Mental Capacity Assessment and Best Interest documentation and link it with needs and risk assessments in social work practice.
Stated completedThe respondent said that this action was complete when they made their response on 17 September 2021. View source
Action
Embed multidisciplinary roles and responsibilities in staff induction, clinical supervision, multi-agency procedures and standards, and refresh related capacity procedures and training.
Stated plannedThe respondent said that this action was planned when they made their response on 17 September 2021. View source
Action
Implement a quality assurance framework incorporating the Mental Capacity Act Competency Framework and a skills and knowledge audit for social workers and managers.
Stated plannedThe respondent said that this action was planned when they made their response on 17 September 2021. View source
Action
Embed the Mental Capacity Act in adult social care practice through forums, social-work training, quality assurance and workforce-development programmes.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 September 2021. View source
Action
Implement the Safeguarding Lead’s programme of learning, case-file audits, learning reviews, staff consultation and feedback to strengthen professional curiosity.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 September 2021. View source See 2 more actions
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AI-generated summary
Irene Ann Esaw · 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
Irene Ann Esaw, who had dementia and was dependent on her grandson for all nutritional, mobility, hygiene and personal care, was discharged from hospital without a formal care package or community referrals. She was later found deceased at home in an emaciated state, with severe untreated pressure sores, tissue damage and widespread sepsis. The principal concerns were failures to assess mental capacity, recognise clinical signs of neglect, and ensure effective multi-agency assessment and working.
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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to complete adequate assessments of patients’ needs
Wider context from the report “3. Multi-agency Working –
My findings reveal that in the treatment of Mrs. Esaw, there were assumptions made by the clinical team and the IUCT that the other agency was responsible for capacity and needs assessments. The effect of this was that there was never an adequate assessment of her needs completed . ████████, the Principal Social Worker for Adult Social Care told me in her evidence that even though IUCT are on the wards at Tameside, there is still further work to be done to understand the roles that the IUCT and the clinical team are undertaking. I am concerned that this continues to need to be addressed.
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to clarify multi-agency responsibility for capacity and needs assessments
Wider context from the report “3. Multi-agency Working –
My findings reveal that in the treatment of Mrs. Esaw, there were assumptions made by the clinical team and the IUCT that the other agency was responsible for capacity and needs assessments . The effect of this was that there was never an adequate assessment of her needs completed. ████████, the Principal Social Worker for Adult Social Care told me in her evidence that even though IUCT are on the wards at Tameside, there is still further work to be done to understand the roles that the IUCT and the clinical team are undertaking . I am concerned that this continues to need to be addressed.
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately assess patients’ mental capacity for care decisions
Wider context from the report “1. Identifying and Assessing Mental Capacity –
My findings in relation to Mrs. Esaw’s death were that there was a fundamental failure by the clinical and nursing staff to adequately consider and assess Mrs. Esaw’s capacity to make decisions about her own care needs whilst she was a patient at Tameside General Hospital between 12ᵗʰ and 28ᵗʰ September 2018. This failure in my view, undermined her discharge planning and was one of the key reasons why the discharge was unsafe. I understand that work is ongoing in this area, but I am concerned having heard the evidence of ████████, the Deputy Director of Nursing and Professional Standards that it is still a “work in progress” identified by this and other incidents reported to the Trust. I am concerned that there are still issues that the Trust aren’t completely compliant with and that this needs to be addressed.
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise clinical indicators of neglect as safeguarding concerns
Wider context from the report “2. Recognising the Clinical Signs of Neglect –
My findings indicate that in 2018 there was no adequate consideration by the clinical or nursing staff that Mrs. Esaw’s clinical presentation in of itself indicated neglect and therefore a safeguarding concern . The Trust’s Safeguarding Lead ████████ told me that following on from the Domestic Homicide Review, the Trust recognises that more work needs to be done around the recognition of what is neglect and those medical indicators of neglect . She recognised that there needs to be a strengthening of recognition in staff of safety concerns . I understand that this is part of the Safeguarding Lead’s portfolio, but I am concerned that this still needs to be addressed.
” 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 Update Mental Capacity Assessment and Best Interest documentation and link it with needs and risk assessments in social work practice.
Verbatim wording from the response “On the 22 July 2020, a 12 month improvement plan was launched, which incorporates standards of practice, themed audits and themed Continuing Professional Development. The Individual Management Report (IMR) recommendations and action plan are annexed to this report as Appendix A.” Source location Response from Tameside and Glossop NHS England
Open published response
×
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 Embed multidisciplinary roles and responsibilities in staff induction, clinical supervision, multi-agency procedures and standards, and refresh related capacity procedures and training.
Verbatim wording from the response “Integral to this, is ensuring that the multidisciplinary team have a good understanding of one another’s roles and responsibilities. Work will take place to ensure that this is embedded in practice. This will include ensuring that roles and responsibilities feature in the induction of all staff, in ongoing clinical supervision and in multiagency procedures and standards. A multiagency review and refresh of the Mental Capacity Act procedures and training regarding adults with care needs on discharge, will take place.” Source location Response from Tameside and Glossop NHS England
Open published response
×
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 Implement a quality assurance framework incorporating the Mental Capacity Act Competency Framework and a skills and knowledge audit for social workers and managers.
Verbatim wording from the response “The Principal Social Worker is currently reviewing the implementation of the quality assurance framework for social work practice, the application of the Mental Capacity Act will feature in this work. The aim is that a new framework will be in place from January 2022. Part of this work will include implementing the National Mental Capacity Act Competency Framework, developed by Bournemouth University. A skills and knowledge audit will take place of social workers and managers and the outcome will inform the ongoing training programme.” Source location Response from Tameside and Glossop NHS England
Open published response
×
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 Embed the Mental Capacity Act in adult social care practice through forums, social-work training, quality assurance and workforce-development programmes.
Verbatim wording from the response “Identifying and Assessing Mental Capacity
Since 2019, one of Adult Social Care work force development priorities has been to improve our staff knowledge and application of the Mental Capacity Act.” Source location Response from Tameside and Glossop NHS England
Open published response
×
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 Implement the Safeguarding Lead’s programme of learning, case-file audits, learning reviews, staff consultation and feedback to strengthen professional curiosity.
Verbatim wording from the response “The Safeguarding Lead started in their role on the 13 September 2021, they are responsible for the implementation of the new Safeguarding Policy and Procedure within Tameside Adult Services. One of the priorities that will run throughout all of their work will be to ensure staff feel confident and equipped to be more ‘professionally curious’. This is recognised safeguarding training and the toolkit, advises that social workers can become more professionally curious and respectfully uncertain by following the points below:” Source location Response from Tameside and Glossop NHS England
Open published response
18 Jul 2017 Ivy Mitchell · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 6 Failure to document observations after a fall View source Failure to comply with escalation processes following a fall View source Lack of understanding of the trigger for referral to the community nutrition team View source Inaccurate falls-risk documentation View source Lack of care home staff understanding of risk assessments View source Lack of understanding of reviews and required post-fall processes View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Ivy Mitchell · 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
Ivy Mitchell, a care home resident with a history of falls, fell on 29 December 2016 and later developed a subcapital fracture and pneumonia. She deteriorated and died on 26 January 2017; concerns included inaccurate falls-risk documentation, inadequate understanding of post-fall processes and observations, failure to escalate appropriately, and lack of understanding about referral to the community nutrition team.
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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to document observations after a fall
Wider context from the report “2. There was a lack of understanding amongst the care home staff of risk assessments; reviews and the required process following a fall. This included documenting observations after a fall .
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to comply with escalation processes following a fall
Wider context from the report “3. Processes relating to escalation following a fall were not complied with ; and
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of the trigger for referral to the community nutrition team
Wider context from the report “4. There was a lack of understanding of the trigger for a referral to the community nutrition team .
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Inaccurate falls-risk documentation
Wider context from the report “1. The documentation relating to the falls risk was inaccurate . It did not refer to previous falls and did not reflect her mobility ;
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of care home staff understanding of risk assessments
Wider context from the report “2. There was a lack of understanding amongst the care home staff of risk assessments ; reviews and the required process following a fall. This included documenting observations after a fall.
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of reviews and required post-fall processes
Wider context from the report “2. There was a lack of understanding amongst the care home staff of risk assessments; reviews and the required process following a fall . This included documenting observations after a fall.
” Open source report
5 Jun 2017 Derrick Lawrence Brocklehurst · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure to recover care notes when care ceased View source Failure to provide discharge summaries to GPs after emergency department attendance View source Lack of documentation of carer visits View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Derrick Lawrence Brocklehurst · 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
Derrick Lawrence Brocklehurst was admitted to hospital after being found immobile and incontinent at home, with grade 4 pressure ulcers, and died on 2 December 2016 from a pulmonary embolus. Concerns included missing records of carer visits and the absence of a discharge summary from the hospital to the GP after his A&E attendance.
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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to recover care notes when care ceased
Wider context from the report “1. There was no documentation available of the carer visits. The care provided and any issues with the provision of care could not be established. They were not recovered by Social Services when care stopped. There was no system for recovery of care notes when care ceased.
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide discharge summaries to GPs after emergency department attendance
Wider context from the report “2. No discharge summary was provided by Tameside General Hospital to the GP after the deceased was seen in A and E.
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of documentation of carer visits
Wider context from the report “1. There was no documentation available of the carer visits. The care provided and any issues with the provision of care could not be established. They were not recovered by Social Services when care stopped. There was no system for recovery of care notes when care ceased.
” 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 Raise and discuss unrecovered care record books with providers at contract performance meetings.
Verbatim wording from the response “d. Where a provider has been unable to recover a care record book the matter will be raised and discussed with the provider at a contracts performance meeting. If necessary and appropriate to do so the Council will require the provider to take steps and measures to address the failure to recover record book.” Source location 2017-0181-Response-by-Tameside-Metropolitan-Borough
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 Run a weekly report of ended care packages and request providers to confirm recovery of each care record book or report recovery attempts and reasons for failure.
Verbatim wording from the response “c. With immediate effect on a weekly basis the Homecare Commissioning Team will run a report identifying which service users have ceased to receive care. The relevant provider will be sent a copy of this report with a request for confirmation that the care record book has been recovered from the service user. Where the provider states records cannot be recovered the provider must notify the Council, detail the attempts that have been made to recover the records and give reasons for not being able to do so;” Source location 2017-0181-Response-by-Tameside-Metropolitan-Borough
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 Remind care providers at the next Provider Forum about care-record maintenance, copying, recovery, failure recording and seven-year archiving obligations, then confirm these requirements in writing.
Verbatim wording from the response “a. The agenda for a Provider Forum, due to take place on 25 July 2017, included an item relating to Care Record Books. Unfortunately this forum was postponed. The item will be included on the agenda for the next Provider Forum at which providers will be reminded of their obligations and in particular the obligation to:” Source location 2017-0181-Response-by-Tameside-Metropolitan-Borough
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 Providers cannot recover care records from a property without cooperation because they cannot enter after care has ended.
Verbatim wording from the response “18. There will be circumstances where the Council and the provider receive no prior notification of care ending (such as when a service user is admitted without notice to hospital and subsequently dies). In such circumstances the provider will be notified by the Home Care Commissioning Team that care has ended. The provider must take steps to try and recover the care record book. The provider will rely on the information of whoever may still be residing at the service user’s home, such as family members and others, to recover the care records. However if cooperation is not forthcoming the provider cannot enter the property to recover the records knowing that the service user isn’t present and that the contract to provide care has ended.” Source location 2017-0181-Response-by-Tameside-Metropolitan-Borough
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 The unavailable care records were considered an isolated incident rather than evidence of a systemic failing.
Verbatim wording from the response “26. The Council regrets that no documents relating to the care visits were available to the Coroner. However the Council believes that this was an isolated incident rather than an example of a systemic failing and it is only very rarely that a care provider is unable to provide to the Council when requested the actual care record book from a service user’s property.” Source location 2017-0181-Response-by-Tameside-Metropolitan-Borough
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 The stated actions and proposals were considered sufficient to minimise the risk of care records being unavailable at future investigations and inquests.
Verbatim wording from the response “28. The Council trusts these actions and proposals are sufficient to satisfy that Coroner that the Council does take this issue seriously, that there is a system in place for the recovery of care record books and that care providers will be advised of their record keeping obligations. This in turn will minimise the risk of care record books not being available at future Investigations and Inquests.” Source location 2017-0181-Response-by-Tameside-Metropolitan-Borough
Open published response
8 Dec 2016 Rachal Marie Murphy · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Failure to undertake annual liver function tests View source Failure to review CAF documentation View source Lack of clarity about referral routes and acceptance by Psychological services View source Delays in reporting EEGs View source Delays in allocation of cases within Early Help Services View source Lack of understanding of cases suitable for CAMHS referral View source Lack of GP involvement in inter-agency case handling View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Rachal Marie Murphy · 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
Rachal Marie Murphy died at home on 8 September 2015 after taking medication prescribed to other family members; the medical cause of death was recorded as acute hypoxia due to morphine overdose, and the conclusion was that she had taken her own life. The report identified concerns about fragmented inter-agency care, failures and delays in referrals and investigations, overlooked CAF documentation, and delays in Early Help case allocation.
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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake annual liver function tests
Wider context from the report “1. There was a failure to undertake annual liver function tests in 2014 and 2015
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to review CAF documentation
Wider context from the report “2. The CAF documentation was completely overlooked and simply placed in the medical records as read only which led to no GP involvement in the inter-agency framework and handling of this case.
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about referral routes and acceptance by Psychological services
Wider context from the report “1. There was a lack of understanding between medical professionals as to the means by which someone could be referred to Psychological services and whether there was a unclear message from Psychological services as to whether they were accepting referrals .
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Delays in reporting EEGs
Wider context from the report “3. There was as significant delay in the reporting of Rachals EEG and the Court heard that this remained the case in respect of reporting of EEGs at the time of the Inquest .
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Delays in allocation of cases within Early Help Services
Wider context from the report “1. The Court heard that there was a significant delay in the allocation of cases within Early Help Services and from the evidence the Court was not satisfied that this had been resolved .
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of cases suitable for CAMHS referral
Wider context from the report “2. Lack of understanding amongst medical professionals as to the cases which may or may not be suitable for referral to CAMHS .
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of GP involvement in inter-agency case handling
Wider context from the report “2. The CAF documentation was completely overlooked and simply placed in the medical records as read only which led to no GP involvement in the inter-agency framework and handling of this case .
” Open source report
16 Apr 2015 Kesia Lena Mary Leatherbarrow · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 28 Failure of the youth diversion project to provide diversion before criminal justice processing View source Failure to record and explain incomplete medical assessments View source Failure to return completed Appropriate Adult forms to Social Services View source Interagency confusion about safeguarding roles and access to information View source Failure to initiate youth offending and mental health monitoring after case transfer View source Failure to pass complete incident information to attending officers View source Inconsistent safeguarding functions across Manchester Multi-Agency Safeguarding Hubs View source Insufficient availability of accommodation for children under 17 View source Insufficient recording of safeguarding information by Appropriate Adults View source Failure of youth offending teams to transfer and oversee cases after relocation View source Failure to assess police information when selecting an Appropriate Adult View source Lack of legally required accommodation for 17-year-olds refused bail View source Failure to make safeguarding referrals from custody medical information View source Failure to record safeguarding intelligence on nominal profiles View source Failure to conduct police database checks on standard-risk DASH referrals View source Failure to route domestic violence cases involving 17-year-old children to child protection review View source Lack of shared understanding between police and MEDACS about requested medical assessments View source Lack of interagency understanding for sharing safeguarding information between police and CPS View source Failure to provide Appropriate Adults with relevant custody risk information View source Failure to provide differentiated mental health assessments for children in custody View source Failure to document information provided to MEDACS before medical assessments View source Failure to check and update Prisoner Escort Records before release View source Custody handovers dependent on officers’ and staff’s unpaid free time View source Lack of consistent child safeguarding coverage across Manchester local authorities View source Lack of clear officer guidance for raising safeguarding concerns View source Unclear referral routes for non-criminal safeguarding concerns View source Lack of a process for recording safeguarding concerns View source Lack of a non-criminal safeguarding policy View source See 25 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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
Kesia Lena Mary Leatherbarrow · 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
Kesia Lena Mary Leatherbarrow, aged 17, died on 3 December 2013 after tying a ligature around her neck. The report describes missed opportunities among multiple agencies to obtain and share information, assess risks, and provide appropriate support, including concerns about her care and information handling while in police custody.
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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure of the youth diversion project to provide diversion before criminal justice processing
Wider context from the report “The court heard evidence that in Tameside this signposting is only taking place to the mental health services once the young person has been processed through the Criminal Justice System and is not in fact acting as a diversion pathway . There was no evidence from those working in custody that any consideration was given to this scheme for Kesia and there appeared to be little knowledge of the scheme .
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to record and explain incomplete medical assessments
Wider context from the report “It was clear that a medical assessment could not be completed and in these circumstances this should be fully explained to the police and the record endorsed accordingly rather than simply endorsing that someone is fit to be detained/interviewed or transferred .
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to return completed Appropriate Adult forms to Social Services
Wider context from the report “Evidence from Tameside Social Services indicated that they did not receive the completed form in relation to Kesia and that it was not unusual not to receive the completed forms in any cases.
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Interagency confusion about safeguarding roles and access to information
Wider context from the report “Having heard the evidence the Court felt that there was a degree of confusion and misunderstanding between all the agencies as to their roles , what they are able and not able to do and also where to access important and effective information .
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to initiate youth offending and mental health monitoring after case transfer
Wider context from the report “This did not occur as the file had not been processed at the time of Kesia’s death but also because of the confusion between the Youth Offending Teams involved with Kesia which meant she was never picked up by Tameside . The plan that Kesia should be monitored for any interim changes in her risk did not therefore occur .
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to pass complete incident information to attending officers
Wider context from the report “The Court heard evidence as to the failure to pass on complete information to the officers who then subsequently attended on Kesia including on one occasion the fact that it had been communicated that she had a knife . The court heard evidence that the failure to pass on important information could impact on the safety of the officers and others and also lead to missed opportunities for safeguarding.
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Inconsistent safeguarding functions across Manchester Multi-Agency Safeguarding Hubs
Wider context from the report “This was not the system in Manchester and the Court heard evidence that the development of MASHs across Manchester is still ongoing. The Court heard evidence that in Manchester different hubs work differently with different agendas – some relate to domestic violence only and not all of them deal with safeguarding of children .
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of accommodation for children under 17
Wider context from the report “The Inquest heard that across Greater Manchester it is estimated that, until recently, in only 10% of cases where the police requested such a service from a local authority a bed was available . Attempts are being made to address this issue but at present the figure remains approximately 20% and the Inquest heard evidence that this was, “not good enough”.
Again the facts heard at this Inquest seem to suggest that children younger than 17 are at risk of being held in custody longer than necessary due to a lack of appropriate facilities . The court heard evidence that the police are in the undesirable position of having to decide whether to detain someone (potentially unlawfully) or release them when they feel it may be unsafe to do so.
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient recording of safeguarding information by Appropriate Adults
Wider context from the report “The quality of the information given by the appropriate adult on the completed form was insufficient in light of all the information which had been made available to her about Kesia and the behaviour she had witnessed. Important information such as the threat made by Kesia was not placed onto the form
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure of youth offending teams to transfer and oversee cases after relocation
Wider context from the report “There was a failure by Lancashire to note her move which led to a delay in her case being transferred, but in addition there was a failure in the communications with Tameside for each team to understand what was being requested and to have oversight of the situation. This led to a lack of involvement with Kesia and a proposal to breach her. It also meant that no effective work was being carried out with her and a missed opportunity to recognise her developing situation in terms of her lack of residence and drug use.
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to assess police information when selecting an Appropriate Adult
Wider context from the report “It was not her understanding of the system in place that she should be assessing the information given to her by the police to consider whether it was more suitable for the attendance of a Social Worker.
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of legally required accommodation for 17-year-olds refused bail
Wider context from the report “There remains no legal requirement for local authorities to provide accommodation for 17 year olds who will then have to remain in police custody if bail is refused. The result is that 17 year old children risk being kept in custody for longer than necessary if there is nowhere suitable for them to be bailed to.
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to make safeguarding referrals from custody medical information
Wider context from the report “Similarly the Court heard that no safeguarding referral was made about Kesia despite information about her self-harming, drug and alcohol use .
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to record safeguarding intelligence on nominal profiles
Wider context from the report “No intelligence was placed on Kesia’s nominal profile despite a number of concerning contacts with her by officers . It is a core function of the police to submit such intelligence.
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct police database checks on standard-risk DASH referrals
Wider context from the report “when a Domestic Abuse, Stalking and Harassment form (DASH) is submitted to the PPI unit, where the risk level is standard then no checks on the Police National Computer or the Police National Database are carried out . The rationale for this was not clear although DC Evans indicated this may be due to the volume of work. Clearly the PNC can hold vital information about a potential offender .
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to route domestic violence cases involving 17-year-old children to child protection review
Wider context from the report “For domestic violence incidents the closing code relates to people over the age of 16 as being adults. This means that the case is not then automatically passed through to the Child Protection Team within Greater Manchester Police for a review even if one of the people involved is still a child - i.e. is 17 years of age.
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of shared understanding between police and MEDACS about requested medical assessments
Wider context from the report “It was apparent to the Court that the expectations of the police as to the precise medical assessment being carried out and the conclusions of the assessment may not always be the same as the expectations and understanding of MEDACS .
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of interagency understanding for sharing safeguarding information between police and CPS
Wider context from the report “There was a lack of understanding between GMP and the CPS as to how such important information should be shared between agencies .
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide Appropriate Adults with relevant custody risk information
Wider context from the report “She was not advised that Kesia had been assessed as intoxicated and arrival, nor that she had been seen by MEDACS , nor that she had threatened to jump off a bridge on her release.
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide differentiated mental health assessments for children in custody
Wider context from the report “The Court also heard evidence that the same medical assessment is carried out for every detained person in custody regardless of whether that is a 17 year old child with mental health difficulties or a 69 year old man with a heart condition. There is no difference in the mental health assessments for children as opposed to adults .
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to document information provided to MEDACS before medical assessments
Wider context from the report “there was no clarity as to whether this included previous risk assessments , whether this was a complete record and there was no recorded evidence to indicate what information had been passed to MEDACS by the police and who had provided the information.
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to check and update Prisoner Escort Records before release
Wider context from the report “The Prisoner Escort Record form was completed over 12 hours prior to Kesia leaving police custody. It was not checked or amended prior to her release and it failed to contain crucial information indicating that whilst in custody Kesia had made a threat to jump from a bridge.
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Custody handovers dependent on officers’ and staff’s unpaid free time
Wider context from the report “The system at present relies on officers and staff attending work early and sometimes staying late after a 12 hour shift to provide a handover. Whilst it is clear there would need to be some overlap in the times people are on duty, the Court heard evidence as to the quality of the handovers which is clearly impacted by the fact that this crucial part of the information sharing process relies entirely on the free-time of officers and staff .
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent child safeguarding coverage across Manchester local authorities
Wider context from the report “This will mean that there is a lack of consistency in approach across the different local authorities in Manchester as to what will be dealt with. Worryingly some will not deal with the safeguarding of children
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of clear officer guidance for raising safeguarding concerns
Wider context from the report “Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal. There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns. There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be recorded.
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Unclear referral routes for non-criminal safeguarding concerns
Wider context from the report “Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal. There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns. There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be recorded.
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a process for recording safeguarding concerns
Wider context from the report “Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal. There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns . There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be recorded.
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a non-criminal safeguarding policy
Wider context from the report “Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal . There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns. There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be recorded.
” Open source report
30 Jan 2014 Leslie Alfred Pates · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 5 Breakdown in communication between the hospital and the family View source Failure to consider the family’s views before discharge planning and implementation View source Failure to hold the required pre-discharge meeting with the family View source Lack of a pressure-relieving mattress at discharge home View source Discharge home with severe pressure sores View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Leslie Alfred Pates · 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
Leslie Alfred Pates was admitted to hospital, discharged home against his family’s wishes, and later transferred to a nursing home before being readmitted to hospital in a deteriorated condition. The principal concerns were failures in communication and discharge planning, including the absence of a family meeting, insufficient consideration of the family’s views, and discharge with severe pressure sores without a pressure-relieving mattress.
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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Breakdown in communication between the hospital and the family
Wider context from the report “1. There has been a complete breakdown in effective communication between the hospital and the family of the deceased .
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to consider the family’s views before discharge planning and implementation
Wider context from the report “2. Neither the hospital staff nor the social services staff took any, or any proper, account of the wishes and views of the family prior to the discharge home of the patient .
3. The patient who was aged 80 years was sent home with severe pressure sores and without the facility of a pressure relieving mattress.
4. Tameside Social Services failed completely or adequately to consider the views of the family of the deceased before determining and bringing into effect a plan for his discharge .
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to hold the required pre-discharge meeting with the family
Wider context from the report “5. The required “meeting” between Social Services and the family prior to discharge from hospital, simply never took place .
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a pressure-relieving mattress at discharge home
Wider context from the report “2. Neither the hospital staff nor the social services staff took any, or any proper, account of the wishes and views of the family prior to the discharge home of the patient.
3. The patient who was aged 80 years was sent home with severe pressure sores and without the facility of a pressure relieving mattress .
4. Tameside Social Services failed completely or adequately to consider the views of the family of the deceased before determining and bringing into effect a plan for his discharge.
” 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 Tameside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Discharge home with severe pressure sores
Wider context from the report “2. Neither the hospital staff nor the social services staff took any, or any proper, account of the wishes and views of the family prior to the discharge home of the patient.
3. The patient who was aged 80 years was sent home with severe pressure sores and without the facility of a pressure relieving mattress.
4. Tameside Social Services failed completely or adequately to consider the views of the family of the deceased before determining and bringing into effect a plan for his discharge.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations