Peter Good · Prevention of Future Deaths report

On 28th June 2024, I opened an inquest into the death of Peter Good who died on 9th January 2024 at Stepping Hill Hospital, Stockport, aged 64 years. The investigation concluded with the inquest which I heard on 17th December 2024.

A post mortem examination undertaken by a consultant forensic pathologist on the Home Office Register determined Mr Good died as a consequence of:

1) a) Pneumonia;

1) b) Cerebral infarction, Parkinson’s disease and skin ulceration.

At the end of the inquest, I recorded a narrative conclusion to the effect that Mr Good died as a consequence of complications arising from a previous cerebral infarction, Parkinson’s disease and skin ulceration which had significantly deteriorated whilst at the nursing home from which he was admitted to hospital for the final time.

Mr Good was a resident at Hilltop Hall Nursing Home who was nursed in bed as a result of complex care needs particularly arising from a previous cerebral infarction. On 26th December 2023, Mr Good was admitted to Stepping Hill Hospital, Stockport with a blocked gastrostomy tube.

On admission, Mr Good was noted to be in poor condition exhibiting what clinical staff perceived as signs of prolonged neglect, leading to a safeguarding alert being raised.

Despite treatment with antibiotics, Mr Good deteriorated further whilst in hospital and died on 9th January 2024.

The court heard evidence that a safeguarding alert was raised by nursing staff at Stepping Hill Hospital shortly after admission on the basis that Mr Good appeared to them very dirty and unkempt with some of his wounds looking and smelling infected. It was further suggested that on admission, Mr Good was noted to exhibit poor oral hygiene, with calculus-covered teeth which the hospital safeguarding nurse regarded as indicative of prolonged neglect.

Whilst the Nursing Home’s Deputy Manager gave evidence to the effect that she did not recognise this description of Mr Good, she accepted she had last provided care to him several weeks prior to his admission to hospital.

I am concerned in the light of this description that Harbour Healthcare as the owner and operator of Hilltop Hall has not instigated its own investigation into the way which Mr Good was cared for, with a view to considering any ongoing risk of harm to other residents and whether any learning can be derived for staff and managers of the home.