David Hall · Prevention of Future Deaths report

On 16th March 2023 I commenced an investigation into the death of David Hall. The investigation concluded on the 2nd August 2023 and the conclusion was one of Narrative: Died from the complications of poor swallow which developed whilst an inpatient where admission had been due to a shortage of a suitable community placement and discharge was delayed due to a shortage of a suitable social care placement. The medical cause of death was 1a) Aspiration Pneumonia and COVID-19; II) Dementia

David Hall had dementia and was admitted to Stepping Hill Hospital as a consequence of there being no safe and suitable place for him to reside when his usual care arrangement could not continue. He was fit and ready for discharge and was awaiting a placement in a suitable care facility. Whilst in the acute hospital setting, he deteriorated rapidly. His nutritional requirements were not fully met and his swallow deteriorated, which led to further weight loss and ultimately to him developing aspiration pneumonia. Whilst an in-patient he contracted covid 19 which impacted his overall health further. He continued to deteriorate and died at Stepping Hill Hospital on 14th March 2023.

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.