Reginald Collins · Prevention of Future Deaths report

On 25th October 2019 I commenced an investigation into the death of Reginald Collins. The investigation concluded on the 10th July 2020 and the conclusion was one of Accidental Death.

The medical cause of death was 1a) Aspiration pneumonia on a background of immobility; 1b) Fracture neck of femur following a fall; and II) Ischaemic heart disease, Frailty

Reginald Collins fell and fractured his neck of femur at The Meadows (Saffron Ward). He was admitted to Stepping Hill Hospital on 13th September and on 14th September he was operated on. He was medically optimised by 19th September 2019. Discharge was delayed due to a suitable placement not being available due to his complex needs. He developed aspiration pneumonia and deteriorated and died at Stepping Hill Hospital on 22nd October 2019.

1. The inquest heard that Mr Collins could have been discharged from 19th September when he was medically optimised. However he remained in an acute hospital setting until his death on 22nd October because of the challenges of finding a suitable EMI placement for him.

2. The inquest heard that an EMI placement would have met his needs in a way that an acute hospital setting could not.

3. The inquest was told that the delay was due in large part to a lack of suitable complex EMI beds both locally and nationally.

4. The delay in his discharge via Adult Social Care meant that an acute hospital bed was not available to the Trust.