PFD report

Reginald Collins · Prevention of Future Deaths report

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Issued 30 Jul 2020•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.

View original report
Concerns
2

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
4

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. Lack of suitable complex EMI bed capacity
    Part of recurring concern: Inadequate specialist placement arrangements for people requiring specialist care
  2. Delays in discharge via Adult Social Care
    Part of recurring concern: Failure to provide timely suitable onward care placements for patients ready for hospital dischargePart of recurring concern: Unreliable hospital discharge processes
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.3

  1. Action

    Operate the Greater Manchester Discharge Pathway and Discharge to Assess system.

    Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 1 October 2020.
  2. Action

    Develop market-shaping and improved care models for people with complex needs.

    Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 1 October 2020.
  3. Action

    Maintain cross-system work to improve hospital discharge.

    Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 1 October 2020.

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

  1. Position

    The local authority had potential provision and appears to have offered it, disputing that discharge was delayed solely by a lack of suitable placement.

    Stated by NHS Greater Manchester Integrated Care BoardDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Lack of suitable complex EMI bed capacity

Wider context from the report

“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. ”

Is this part of a recurring concern?

Yes — Inadequate specialist placement arrangements for people requiring specialist care.

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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

Delays in discharge via Adult Social Care

Wider context from the report

“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. ”

Is this part of a recurring concern?

Yes — Failure to provide timely suitable onward care placements for patients ready for hospital discharge; Unreliable hospital discharge processes.

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

Operate the Greater Manchester Discharge Pathway and Discharge to Assess system.

Verbatim wording from the response

“As some additional information, as part of the work of the Greater Manchester Adult Social Care Transformation Programme led by the GMHSCP, there is a significant amount of work taking place around market shaping and development and in particular around new and improved models of care and support for people with complex needs. We recognise this is an area which needs improving nationally. We are also working closely across the system on hospital discharge and now have a GM Discharge Pathway and good Discharge to Assess (D2A) system in place.”

Source location

2020-0146-Response-from-Greater-Manchester-Combined-Authority_Redacted.pdf
Page 2 · response
Published 1 October 2020

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

Develop market-shaping and improved care models for people with complex needs.

Verbatim wording from the response

“As some additional information, as part of the work of the Greater Manchester Adult Social Care Transformation Programme led by the GMHSCP, there is a significant amount of work taking place around market shaping and development and in particular around new and improved models of care and support for people with complex needs. We recognise this is an area which needs improving nationally. We are also working closely across the system on hospital discharge and now have a GM Discharge Pathway and good Discharge to Assess (D2A) system in place.”

Source location

2020-0146-Response-from-Greater-Manchester-Combined-Authority_Redacted.pdf
Page 2 · response
Published 1 October 2020

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

Maintain cross-system work to improve hospital discharge.

Verbatim wording from the response

“As some additional information, as part of the work of the Greater Manchester Adult Social Care Transformation Programme led by the GMHSCP, there is a significant amount of work taking place around market shaping and development and in particular around new and improved models of care and support for people with complex needs. We recognise this is an area which needs improving nationally. We are also working closely across the system on hospital discharge and now have a GM Discharge Pathway and good Discharge to Assess (D2A) system in place.”

Source location

2020-0146-Response-from-Greater-Manchester-Combined-Authority_Redacted.pdf
Page 2 · response
Published 1 October 2020

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

The local authority had potential provision and appears to have offered it, disputing that discharge was delayed solely by a lack of suitable placement.

Verbatim wording from the response

“sight of all the relevant information. The Local Authority did have potential provision and it appears did actually offer this. Can we suggest that contact is made with them for further information and clarification on these points. The DASS is more than happy to liaise accordingly (████████@stockport.gov.uk).”

Source location

2020-0146-Response-from-Greater-Manchester-Combined-Authority_Redacted.pdf
Page 2 · response
Published 1 October 2020

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

The local authority is responsible for providing further information and clarification about potential provision and the offer made.

Verbatim wording from the response

“sight of all the relevant information. The Local Authority did have potential provision and it appears did actually offer this. Can we suggest that contact is made with them for further information and clarification on these points. The DASS is more than happy to liaise accordingly (████████@stockport.gov.uk).”

Source location

2020-0146-Response-from-Greater-Manchester-Combined-Authority_Redacted.pdf
Page 2 · response
Published 1 October 2020

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.1

  1. 1

    Continue supporting and driving the Home First approach, including the Living Well at Home Programme.

    Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 1 October 2020.

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 supporting and driving the Home First approach, including the Living Well at Home Programme.

Verbatim wording from the response

“The huge pressures on Trusts is fully acknowledged and we continue to support and drive the ‘Home First’ approach as evidenced in the majority of work including our Living Well at Home Programme here in GM.”

Source location

2020-0146-Response-from-Greater-Manchester-Combined-Authority_Redacted.pdf
Page 2 · response
Published 1 October 2020

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