Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0347, written 4 Nov 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Nov 2022 |
|---|---|
| Reference | 2022-0347 |
| Deceased | Lynn Moss |
| Coroner | Chris Morris |
| Coroner area | Manchester South |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Care.
CORONER
I am Chris Morris, Area Coroner for Manchester South.
Secretary of State for Health and Social
CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and
regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
INVESTIGATION and INQUEST
On 31st March 2022, Alison Mutch OBE, Senior Coroner, opened an inquest into the death of Lynn
Moss who died on 12th March 2022 at Tameside General Hospital, Ashton-under-Lyne, aged 75
years. The investigation concluded with an inquest which I heard on 28th October 2022.
The inquest determined that Mrs Moss died as a consequence of:-
1a) Sepsis;
1b) Lobar pneumonia;
II) Rhabdomyolysis due to immobility after a fall at home, chronic liver disease, hypertension.
The conclusion of the inquest was one of Accident.
CIRCUMSTANCES OF THE DEATH
Mrs Moss had been in poor health for a number of years and was effectively housebound. On 11th
March 2022, her son found her on the floor at her home, having apparently fallen or collapsed. It
was evident to him Mrs Moss was seriously unwell and had probably been on the floor for a
considerable period of time.
An ambulance was called and Mrs Moss was taken to Tameside General Hospital where, despite
treatment, she sadly died the following day.
CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion
there is a risk that future deaths will occur unless action is taken. In the circumstances it is my
statutory duty to report to you.
The MATTERS OF CONCERN are as follows. –
Over the course of the inquest, the court heard evidence to the effect that:
1. Despite the seriousness of her condition, Mrs Moss waited over 5 hours from arrival at the
Emergency Department until she was fully assessed by a doctor;
2. Mrs Moss waited for around 19 hours in the Emergency Department before a bed was to
become available for her on the Acute Medical Unit;
3. Across both units, there were a number of missed opportunities to recognise a deterioration
in Mrs Moss’s condition.
The court heard as to a number of steps the Trust has taken locally to reduce risk to patients
including increasing initiation of treatment prior to medical review, and making plans to expand the
footprint of the Emergency Department.
Notwithstanding such measures, it is a matter of residual concern that systemic problems within the
health and social care sectors including difficulty in accessing primary care and delayed discharges
combine to lead to persistently high levels of demand on hospital Emergency Departments. Such
sustained demand makes timely and effective monitoring of a patient’s condition (and the delivery
of urgent treatment where indicated) increasingly difficult, thus creating an ongoing risk of future
deaths.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you and your
organisation have the power to take such action.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by
30th December 2022. I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out the
timetable for action. Otherwise you must explain why no action is proposed.
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner, Mrs Moss’ family, together with Weightmans
LLP on behalf of the Mental Health Trust.
I have also sent a copy to the Care Quality Commission and Tameside Metropolitan Borough Council
who may find it useful or of interest.
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may
send a copy of this report to any person who he believes may find it useful or of interest. You may
make representations to me, the coroner, at the time of your response, about the release or the
publication of your response by the Chief Coroner.
Dated: 4th November 2022
Signature: Chris Morris HM Area Coroner, Manchester South.
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