Terence Davenport

Date:  08 December 2023 

Ms A Mutch  
HM Senior Coroner 
South Manchester 

Dear Ms Mutch, 

          4th Floor   

                          3 Piccadilly Place 
    London Road 
       Manchester 
 M1 3BN 

Re: Regulation 28 Report to Prevent Future Deaths  

Thank you for your Regulation 28 Report dated 17th October 2023 concerning the sad death of 
Terrence Davenport on 24th September 2023. On behalf of NHS Greater Manchester Integrated Care 
(NHS GM), We would like to begin by offering our sincere condolences to Mr Davenport’s family for their 
loss. 

Thank you for highlighting your concerns during Mr Davenport’s Inquest which concluded on 23rd August 
2023.  On behalf of NHS GM, we apologise that you have had to bring these matters of concern to our 
attention.  We recognise it is very important to ensure we make the necessary improvements to the 
quality and safety of future services.   

Following the inquest, you raised concerns in your Regulation 28 Report to NHS GM that there is a risk 
a future death will occur unless action is taken. The medical cause of death was 1a) Pneumonia on the 
background of the fractured left neck of femur (operated); II) Dementia (mixed type), ischaemic heart 
disease.   

I hope the response below demonstrates to you and Mr Davenport’s family that NHS GM has taken the 
concerns you have raised seriously and will learn from this as a whole system.  

This letter addresses the issues that fall within the remit of NHS GM and how we can share the learning 
from this case. 

The inquest heard evidence that the acute hospital setting was difficult for Mr Davenport due to 
his dementia and created risks to his health once he was medically optimised. He had to remain 
there due to a lack of suitable care/nursing beds. This meant that he was in an unsuitable care 
setting and that a bed that could have been utilised for an acute patient was not available. 

Ensuring acute capacity is available in our hospitals is an ongoing and significant challenge across 
Greater Manchester.  In Tameside, there is a Home Finder Team based in the Integrated Urgent Care 
Team (IUCT) at Tameside Integrated Care Foundation Trust who work with patients and families to 
facilitate a timely and appropriate discharge for medically optimised patients so acute beds can be made 
available.  

We know that Mr Davenport was assessed by the Multi-Disciplinary Team (MDT) as requiring a general 
nursing bed and the Home Finders Team contacted several community providers of general nursing care 
in both Tameside and in the Greater Manchester footprint to identify an appropriate discharge.   

4th Floor, Piccadilly Place, Manchester  M1 3BN   
www.gmintegratedcare.org.uk 

 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 Unfortunately in Mr Davenport’s case, additional issues including dependency levels of existing residents 
and workforce issues meant that none of the providers identified to provide the support were able to 
safely accept Mr Davenport into their care. The situation was also impacted as Mr Davenport’s 
assessments fluctuated between him being medically fit for discharge and requiring ongoing treatment.  
We acknowledge that these factors unfortunately impacted the ability to discharge Mr Davenport in a 
timely manner to an appropriate community placement.  

In respect of Mr Davenport’s support whilst he was in hospital I understand a number of different 
mechanisms were put in place to support Mr Davenport whilst he was awaiting appropriate placement. 
In addition to the Ward supporting with his care and support needs he received additional input from 
dietetics, the complex discharge team, and the physiotherapist.  He was also reviewed by the specialist 
dementia team and Admiral nurses and I understand that Mr Davenport was moved to a bed nearer to a 
window and specialised equipment (RITA) enabled Mr Davenport to watch Western Movies which he 
enjoyed.   

The need for timely discharge whilst ensuring appropriate placements is recognised as an ongoing 
challenge in Tameside (and more widely). In order to support acute bed capacity the following processes 
have been put in to place: 

1.  Home Finders Team (as described above) that are focussed specifically on supporting timely 
and appropriate placements for patients ready for discharge. This Team work closely with 
patients, families and providers to facilitate a supportive discharge. 

2.  Tameside locality partners meet weekly in an Executive Length Of Stay meeting to consider 

any barriers to discharging patients with “No Criteria to Reside”1 (NCTR) and work together to 
identify and remove any barriers to appropriate discharge. The number of patients with NCTR 
are monitored continuously both locally and at GM level to inform understanding of the 
capacity of the system to meet ongoing needs of the population.  

3.  Tameside Digital Health Team (based at Tameside ICFT) provide a face to face digital 

service directly with Residential and Nursing Homes to support residents to remain in the 
Care Sector with support wherever possible. They will also support in working with 
Residential and Nursing Homes to support residents in the Home once they have been 
discharged.  

4.  The Integrated Urgent Care Team is Tameside’s urgent response team; they provide rapid 

assessments for people in the community, with an aim to keeping people in their own homes 
and preventing hospital admission. They have a combination of health and social care staff to 
provide a holistic assessment. They also provide physio support for people in 24-hour care to 
help improve mobility following an acute health issue or fall.  

In addition to the above there is a significant focus in Tameside on the quality of care provided across 
the locality. Tameside have a specialist Quality Improvement Team in place who work with providers to 
improve the quality of care they provide to residents. This includes a specialist Quality Improvement 
Nurse whose work is focussed on Nursing Home provision in the borough. Additionally, our contractual 
performance documentation is heavily focussed on ensuring personalised good quality care.  

1 The phrase "No Criteria to Reside" is used in the context of discharging patients from a hospital. According to national 
guidelines, patients are discharged when they no longer meet the 'Criteria to Reside'. This means that patients who are 
'medically optimised' but require ongoing health and/or social care input should be transferred to a non-acute setting 

4th Floor, Piccadilly Place, Manchester  M1 3BN   
www.gmintegratedcare.org.uk 

 
   
 
 
 
 
 
 
 
 
 System-wide market risks across GM have been escalating over the past 9-12 months, with the highest 
in the nursing care market. Impact on residents and the workforce continues to be minimised by system 
leaders and providers when nursing homes exit the market either by de-registering/ownership or closure. 
We anticipate that there will be more closures over the coming months, and that these will continue to be 
managed locally with as least impact as possible. A system-wide mitigation plan focussing on workforce 
and market development has been developed to support providers to remain resilient over Winter and 
into the medium-term. 

The inquest was told that resident who pushed Mr Davenport was not suitable for placement at 
the care home where the incident happened. The care home where previous incidents had 
occurred was out of area. The inquest was told that lack of information sharing between two GM 
local authorities, the care homes involved and GMP meant that the safeguarding issue was not 
recognised. It was unclear if this was due to an effective information sharing protocol not 
existing between local authorities/care homes/GMP in Greater Manchester or it not being adhered 
to. However, the impact was that the risk of harm was not understood, and staff and residents 
were put at risk. 

As part of movement across settings robust information sharing particularly around any risk elements is 
vital for patient safety. With regards to processes in place for new residents (and specifically in regard to 
people moving between care homes), there should be three sources of information that support 
identification of risks and appropriate placement and subsequent care planning.  

1.  The assessment from the original care home – this should include robust information about the 

person, including risk assessments, behaviours, etc.  Where the patient has been the subject of a 
safeguarding, the care plan should have been updated to reflect potential risks. 

2.  The support plan from the placing authority – which should clearly identify the assessed needs, 
risks, etc.  Similarly, where the patient has been the subject of a safeguarding, the support plan 
should have been updated to reflect this. 

3.  The pre-admission form used by care homes to gather information to assess suitability – this 

should identify basic need information as well as gathering additional information on behaviours 
to help inform risk assessments, which will help determine if the care home can meet the 
patient’s needs alongside the existing residents’ needs. 

Whilst processes are in place for information sharing both within and between localities, we recognise 
that information sharing between partners (as described above) is not always as robust as it should be. 
Additionally, it is recognised that current system pressures requiring patients to be moved to a 
community setting quickly may impact the quality of information being provided.   

We acknowledge that although there are processes in place there is a need for services to use these 
processes robustly to support future safety of residents and support appropriate placements of residents. 

With a focus on learning from this Prevention of Future Deaths Report the following actions are being 
taken locally via Tameside locality to work to support this: 

1)  In Tameside part of our contractual and quality management oversight is around ensuring that there 

are robust pre-admission assessments undertaken and subsequent care planning is undertaken in 
line with assessment or risk. A separate communication will be sent to providers to include learning 
from Mr Davenport’s case, highlighting to Homes the importance of robust pre-admission risk 
assessments and subsequent personalised care planning around a resident’s needs whilst factoring 
wider impact i.e., environmental and impact on other residents, families, and staff.  

4th Floor, Piccadilly Place, Manchester  M1 3BN   
www.gmintegratedcare.org.uk 

 
   
 
 
 
 
 Additionally learning from this report will be presented to Tameside Care Home Managers in 
December 2023; the learning will focus on sharing risk information across settings as well as 
completing robust pre-admission risk assessments. An additional face to face session will take place 
in February; this will be attended by ICFT Trust Colleagues with a focus on issues around discharge 
and transfer between community and acute settings.  

2)  Learning from this case will also be taken via Tameside System Quality Group which is attended by 
Senior colleagues from both TMBC and Tameside Integrated Care Foundation Trust.  The focus will 
be on partnership working and managing risk across settings, and there will be a decision taken 
around the need for any additional work required to support safe discharges and facilitate partnership 
working to mitigate risks particularly within the current pressured position.  

3)  Wider Learning via NHS Greater Manchester – learning will be shared via the GM System Quality 
around ensuring robust information being shared when patients are moving across settings and 
localities, this is particularly important currently due to current pressures on discharge.  

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.  

We hope this response demonstrates to you and Mr. Davenport’s family that NHS GM has taken the 
concerns you have raised seriously and is committed to working together as a system including our 
service users, carers and families to improve the care provided.  

Thank you for bringing these important patient safety issues to our attention and please do not hesitate 
to contact me should you need any further information. 

Yours sincerely 

Chief Nursing Officer 
NHS Greater Manchester  

Place Base Lead 
NHS Greater Manchester - Tameside 

4th Floor, Piccadilly Place, Manchester  M1 3BN   
www.gmintegratedcare.org.uk