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Investigation and inquest
On Wednesday 5th January 2022 I commenced an investigation into the death of Victoria Cartwright, 36. The investigation concluded at the end of the inquest on Thursday 16th June 2022.
The medical cause of death was:
1a) Hypothermia
2) Alcohol Intoxication
The conclusion of the inquest was ‘Accident’.
Circumstances of the death
The deceased was pronounced dead on the 26th December 2021, in the car park, rear of the Ball and Boot pub, Orchard Street, Wigan.
The deceased had a complicated medical history including a long battle with alcohol abuse, resulting in many hospital admissions, as a consequence of being found in the street intoxicated and unable to take care of herself. The deceased had completed a private detoxification and rehabilitation programme but despite this was unable to abstain from alcohol misuse. She was known her to local alcohol and mental health teams.
On the 10th November 2021, she was admitted to hospital by the Police following welfare concerns. On the 19th November 2021, a Mental Health Team referral was made and an assessment revealed an impression that the deceased was suffering from alcohol related brain disease and Korsakoff’s Syndrome. A Mental Health Clinician recommended a 24 hour care placement but put in place as the deceased would be unable to manage independently.
Despite this recommendation, the deceased was discharged from hospital to a hotel used to house homeless individuals and the Mental Health Clinician was not notified of this decision.
The deceased was readmitted back to hospital on the 21st December 2021, due to alcohol intoxication and the Mental Health Clinician reiterated that the deceased would require a 24 hour care placement and a Safeguarding and Social Care referral was made.
From the evidence available, it is not possible to state the exact circumstances of when the deceased was next discharged from hospital.
Closed circuit television footage reveals that on the 25th December 2021 at 20:35 hours, the deceased got out of a car and sat on a bench, before staggering to the location in the car park, rear of the Ball and Boot Pub where she was discovered dead in the next day, on the 26th December 2021, wearing unsuitable clothing for the weather conditions.
Toxicology analysis reveals she had consumed large amounts of alcohol in the period leading to death. The Post Mortem findings conclude she had died from Hypothermia, which she developed whilst being under the influence of alcohol.
There was no third-party involvement.
Coroner’s concerns
████████ Consultant Psychiatrist for Greater Manchester Mental Health Trust stated he had recommended a 24 hour care placement for Victoria to meet her clinical needs. Despite this, she was discharged from hospital to the Mercure Hotel, used to house homeless individuals.
████████ stated that this hotel would have been unsuitable for Victoria’s medical needs and following her readmission back to hospital, raised similar concerns. He also stated that he was never notified of Victoria’s actual discharges.
████████ a Recovery Co-Ordinator, employed by We Are With You (formerly Achieve) stated he was never invited to Victoria’s MDT meeting and it would have been beneficial for his organisation to have been taken part in this meeting. He concurred that the Mercure Hotel would have been unsuitable accommodation to suit Victoria’s complex needs and was not involved in the hospital discharge processes.
Evidence highlights a lack of collaborative working between the discharge team, Wigan Hospital, GMMH and Achieve.
Information checked against the published report and official responses