Doreen Swann · Prevention of Future Deaths report

On16th January 2025 I commenced an investigation into the death of Doreen Swann. The investigation concluded on the 5th June 2025 and the conclusion was one of Narrative: Died from the complications of a fall when not being cared for in compliance with her risk assessment. The medical cause of death was 1a) Traumatic brain injury 1b) Fall II) Advanced dementia, frailty, E. coli septicaemia, bronchopneumonia.

Doreen Swann was a patient at Tameside General Hospital who had been medically optimised and was awaiting discharged when she developed a further infection. She was a high falls risk. She fell whilst unobserved and when the bed rails were up when they should not have been. She suffered a traumatic brain injury and died at Tameside General Hospital on 13th January 2025.

1. The inquest heard evidence that Doreen Swann was only in hospital at the point of her fall because her discharge had been delayed due to a shortage of a suitable social care placement. The evidence was that nursing/caring for high falls risk patients in an acute setting is challenging and resource intensive.

2. The evidence given to the inquest was that this delayed discharge and the ongoing risk it presents was not an isolated incident at TGH -as an example the evidence given was that there were regularly 30 plus patients with a delayed discharge over 3 weeks due to a lack of social care beds .The evidence indicated that this challenge was not unique to Tameside.

3. The evidence indicated that managing a falls risk and the consequential risk to life is better managed outside an acute setting once the clinical need for a hospital stay has passed.

4. Delayed discharges such as Doreen Swann’s reduces the availability of beds for other patients and creates a knock-on impact across the hospital particularly in relation to the Emergency Department.