PFD report

Thomas Barton · Prevention of Future Deaths report

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Issued 21 Jul 2023•Manchester South

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
2

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
9

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Risk of deconditioning and infection for frail elderly patients during unnecessary hospital stays
  2. Insufficient availability of suitable social care causing delayed hospital discharges
    Part of recurring concern: Failure to provide timely suitable onward care placements for patients ready for hospital dischargePart of recurring concern: Insufficient social and community care provision to meet care and discharge needs
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 a recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. Action

    Continue working with NHS and local authorities to roll out care transfer hubs across the country for complex discharges.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 28 July 2023.
  2. Action

    Publish Hospital Discharge and Community Support Guidance setting out hospital discharge and community support processes.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 28 July 2023.
  3. Action

    Provide and increase the Adult Social Care Discharge Fund to support additional care packages, beds, equipment and social care workforce capacity.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 28 July 2023.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    NHS GM considers commissioned home-from-hospital support and existing care capacity sufficient to support timely hospital discharges.

    Stated by NHS Greater Manchester Integrated Care BoardExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Risk of deconditioning and infection for frail elderly patients during unnecessary hospital stays

Wider context from the report

“The inquest heard that the delayed discharge of Mr Barton from hospital was due to the challenges of putting an appropriate social care package in place. The evidence before the inquest was that delayed discharges such as Mr Barton’s put the lives of frail elderly patients at risk as it is far more likely that they will become deconditioned and develop an infection if they spend unnecessary time in hospital. The evidence was that delayed discharges such as Mr Barton’s were not uncommon due to the demand on social care and the availability of suitable care. The evidence was that speedier discharges would occur if there was improved availability of social care and that this would improve outcomes for elderly patients and reduce the risk of preventable deaths occurring. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Insufficient availability of suitable social care causing delayed hospital discharges

Wider context from the report

“The inquest heard that the delayed discharge of Mr Barton from hospital was due to the challenges of putting an appropriate social care package in place. The evidence before the inquest was that delayed discharges such as Mr Barton’s put the lives of frail elderly patients at risk as it is far more likely that they will become deconditioned and develop an infection if they spend unnecessary time in hospital. The evidence was that delayed discharges such as Mr Barton’s were not uncommon due to the demand on social care and the availability of suitable care. The evidence was that speedier discharges would occur if there was improved availability of social care and that this would improve outcomes for elderly patients and reduce the risk of preventable deaths occurring. ”

Is this part of a recurring concern?

Yes — Failure to provide timely suitable onward care placements for patients ready for hospital discharge; Insufficient social and community care provision to meet care and discharge needs.

Open source report

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

Continue working with NHS and local authorities to roll out care transfer hubs across the country for complex discharges.

Verbatim wording from the response

“In January 2023, NHS England published the Urgent and Emergency Care Recovery Plan. This year, and in line with the commitments in this plan, we continue to work with the NHS and local authorities to roll out care transfer hubs in every part of the country to manage discharges for patients with more complex needs. These hubs bring together professionals from the NHS and local authority to manage discharges for people with more complex needs, who need extra support when being discharged.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 28 July 2023

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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

Publish Hospital Discharge and Community Support Guidance setting out hospital discharge and community support processes.

Verbatim wording from the response

“It is our priority to ensure that all patients receive safe and timely discharges from hospital. The Hospital Discharge and Community Support Guidance published by the Department of Health and Social Care, sets out how the discharge process should operate in practice, and how NHS bodies and Local Authorities should work together to plan and implement hospital discharge, recovery and reablement in the community. NHS bodies and local authorities have a statutory duty to cooperate in exercising their”

Source location

Response from Department of Health and Social Care
Page 1 · response
Published 28 July 2023

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

Provide and increase the Adult Social Care Discharge Fund to support additional care packages, beds, equipment and social care workforce capacity.

Verbatim wording from the response

“We put in place £500million for the 2022/2023 Adult Social Care Discharge Fund and this enabled more people to be discharged from hospital in a timely manner. We have since increased the Fund to £600million for the 23/24 and to £1billion for 24/25. This funding has so far been used to deliver additional care packages and beds, provide equipment to support people in returning home, and boost the social care workforce. Local authorities and NHS integrated care boards have the flexibility to spend their allocations in ways they deem most appropriate for their local area. Funding must be spent on measures which seek to free up the maximum number of hospital beds and reduce bed days lost, for example short-term packages of care, community-based reablement capacity, or building the workforce capacity needed to continue to support care users.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 28 July 2023

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

Fund home-from-hospital support from voluntary and community organisations alongside independent care providers.

Verbatim wording from the response

“Response from NHS GM: Whilst we appreciate that during the period of time that Mr Barton was in hospital there was increased demand on care at home, we are confident that there is sufficient capacity to support timely discharges from hospital for people to return to their homes. Supported by NHS GM funding, localities have commissioned home from hospital support from voluntary/community organisations in addition to the independent care providers that provide substantive services.”

Source location

Response from Greater Manchester Integrated Care
Page 3 · response
Published 28 July 2023

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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

Undertake capacity and demand modelling of homecare and care-home markets to inform local market development.

Verbatim wording from the response

“NHS GM have recently undertaken capacity and demand modelling of home care and care home markets. Localities are using the detailed modelling and analysis to inform development and shaping of their market, to ensure that it continues to meet the needs of current and future Greater Manchester residents.”

Source location

Response from Greater Manchester Integrated Care
Page 3 · response
Published 28 July 2023

Open published response

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

NHS GM considers commissioned home-from-hospital support and existing care capacity sufficient to support timely hospital discharges.

Verbatim wording from the response

“Response from NHS GM: Whilst we appreciate that during the period of time that Mr Barton was in hospital there was increased demand on care at home, we are confident that there is sufficient capacity to support timely discharges from hospital for people to return to their homes. Supported by NHS GM funding, localities have commissioned home from hospital support from voluntary/community organisations in addition to the independent care providers that provide substantive services.”

Source location

Response from Greater Manchester Integrated Care
Page 3 · response
Published 28 July 2023

Open published response

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

Trafford Council considers existing homecare, residential care and supported-living provision sufficient in those areas, despite identified specialist capacity gaps.

Verbatim wording from the response

“As indicated above, there is a reasonable supply of homecare currently.”

Source location

Response from Greater Manchester Integrated Care
Page 2 · response
Published 28 July 2023

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. 1

    Publish an evaluation of the 2022/23 Adult Social Care Discharge Fund and its impact on delayed discharges.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 28 July 2023.
  2. 2

    Monitor key learning points and recommendations to ensure they become embedded in practice.

    Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 28 July 2023.
  3. 3

    Present and share learning with the Greater Manchester System Quality Group for incorporation into commissioned services.

    Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 28 July 2023.
  4. 4

    Cascade shared learning from this and similar cases to professionals through governance and learning forums.

    Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 28 July 2023.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Trafford Council cannot develop the scale of extra-care provision required because developers prefer more profitable care-home developments.

    Stated by NHS Greater Manchester Integrated Care BoardUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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

Publish an evaluation of the 2022/23 Adult Social Care Discharge Fund and its impact on delayed discharges.

Verbatim wording from the response

“We have published an evaluation of the 2022/23 discharge fund which has explored how local areas spent their funding. We found evidence that funding was associated with a positive impact on delayed discharge with local areas reporting a reduction in delayed discharges, and improved flow through the system.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 28 July 2023

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

Monitor key learning points and recommendations to ensure they become embedded in practice.

Verbatim wording from the response

“In conclusion, key learning points and recommendations will be monitored to ensure they are embedded within practice. NHS GM is committed to improving outcomes for the population of Greater Manchester.”

Source location

Response from Greater Manchester Integrated Care
Page 3 · response
Published 28 July 2023

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

Present and share learning with the Greater Manchester System Quality Group for incorporation into commissioned services.

Verbatim wording from the response

“Actions taken or being taken to share learning across Greater Manchester:”

Source location

Response from Greater Manchester Integrated Care
Page 3 · response
Published 28 July 2023

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

Cascade shared learning from this and similar cases to professionals through governance and learning forums.

Verbatim wording from the response

“2. Shared learning from this and similar cases at Greater Manchester and borough level will be cascaded to professionals through relevant governance and learning forums to ensure that learning is incorporated into their services.”

Source location

Response from Greater Manchester Integrated Care
Page 3 · response
Published 28 July 2023

Open published response

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

Trafford Council cannot develop the scale of extra-care provision required because developers prefer more profitable care-home developments.

Verbatim wording from the response

“National modelling estimates the number of extra care units required in Trafford as being 96. Developers prefer to build care homes rather than extra care as the returns are more profitable. The Council is not able to develop the scale of extra-care provision required but is committed to work with partners to maximise relevant developments.”

Source location

Response from Greater Manchester Integrated Care
Page 2 · response
Published 28 July 2023

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026