George Coulthard

HSCA Further Information 
Citygate 
Gallowgate 
Newcastle upon Tyne 
NE1 4PA 

Alison Mutch OBE 
HM Senior Coroner 
1 Mount Tabor Street 
Stockport 
SK1 3AG 

Via email:

18 November 2024 

Our Reference: 
Your reference: 

Dear HM Senior Coroner Alison Mutch OBE, 

Prevention  of  future  death  report  following  inquest  into  the  death  of  Mr  George 
Neville Coulthard. 

Thank  you  for  sending  CQC  a  copy  of  the  prevention  of  future  death  report  issued 
following the sad death of Mr George Neville Coulthard. 

We  note  the  legal  requirement  upon  the  Care  Quality  Commission  to  respond  to  your 
report within 56 days, by the 19 November 2024. 

Thank you for your clarification that the care home referred to in points 2 and 3 is Hilltop 
Hall  Nursing  Home.  The  registered  provider  of  Hilltop  Hall  Nursing  Home  is  Harbour 
Healthcare Limited. They have been registered with CQC as a service provider since 27 
November 2012.   

The provider’s location, Hilltop Hall Nursing Home is located at Dodge Hill, Heaton Norris, 
Stockport, Cheshire, SK4 1RD. At the time of Mr Coulthard’s residence, the provider was 
registered for the regulated activities: ‘Accommodation for persons who require nursing 
or personal care’ and ‘Treatment of disease, disorder or injury’. 

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 Hilltop Hall does not currently have a manager who is  registered with CQC to oversee 
and manage the delivery of the regulated activities at this location, in contravention of the 
condition imposed on this provider’s registration for this location, stating that they must 
have  a  registered  manager  in  post.  CQC  will  write  to  the  registered  provider  to  seek 
clarification on when they propose to register a manager and may take action against the 
provider if we are dissatisfied with the actions they have taken to meet this condition of 
registration. 

The role of CQC and Inspection methodology 

The role of the Care Quality Commission (CQC) as an independent regulator is to register 
health and adult social care service providers in England and to assess/inspect whether 
the  fundamental  standards  set  out  in  the  Health  and  Social  Care  Act  2008,  and 
amendments, are being met.   

The regulatory approach used during previous inspections of Hilltop Hall Nursing Home 
considered  five  key  questions.  They  asked  if  services  were  Safe;  Effective;  Caring; 
Responsive; and Well Led.  Inspectors used a series of key lines of enquiry (KLOEs) and 
prompts  to  seek  and  corroborate  evidence  and  reassurance  of  how  the  provider 
performed  against  characteristics  of  ratings  and  how  risks  to  service  users  were 
identified, assessed and mitigated.   

The  regulatory  framework  includes  providers  being  required  to  meet  fundamental 
standards of care; the standards below which care must never fall.  We provide guidance 
to providers on how they can meet these standards (Regulations 4 to 20A of the Health 
and Social Care Act 2008 (Regulated Activities) Regulations 2014).  

On 6 February 2024 CQC’s Operations Network in the North region went live with our 
new Single Assessment Framework. This approach covers all sectors, service types and 
levels and the five key questions remain central to this approach. However, the previous key 
lines of enquiry (KLOEs) and prompts have been replaced with new ‘quality statements’. The 
quality  statements  are  described  as  ‘we  statements’  as  they  have  been  written  from  a 
provider’s  perspective  to  help  them  understand  what  we  expect  of  them.  They  draw  on 
previous  work  developed  with  Think  Local  Act  Personal  (TLAP),  National  Voices  and  the 
Coalition for Collaborative Care on Making it Real. They set clear expectations of providers, 
based on people’s experiences and the standards of care they expect. We have introduced 
six  new  evidence  categories  to  organise  information  under  the  statements;  these  are 
feedback  from  people,  feedback  from  staff  and  leaders,  feedback  from  partners,  our 
observations, processes and outcomes.  This approach will allow CQC to use a range of 
information to assess providers flexibly and frequently, collect evidence on an ongoing basis 

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 and  update  ratings  at  any  time;  tailor  our  assessment  to  different  types  of  providers  and 
services; score evidence to make our judgements more structured and consistent; use site 
visits  and  data  and  insight  to  gather  evidence  to  assess  quality  and  produce  shorter  and 
simpler reports, showing the most up-to-date assessment. 

Regulatory History 

Hilltop  Hall  was  last  inspected  in  January  2024,  as  part  of  our  routine  schedule  of 
inspections (just prior to the introduction of our Single Assessment Framework). During 
this  inspection  we  looked  at  all  5  Key  Questions.  We  rated  the  key  questions  ‘Is  the 
service  caring’  and  ‘Is  the  service  responsive’  as  requires  improvement  and  the  key 
questions  ‘Is  the  service  safe’,  ‘Is  the  service  effective’  and  ‘Is  the  service  well-led'  as 
inadequate, and the overall rating for the service was inadequate. The service was found 
to be in breach of regulations relating to safe care and treatment, fit and proper persons 
employed,  meeting  nutritional  and  hydration  needs,  need  for  consent,  staffing,  person 
centred care and good governance. In instances where CQC have decided to take civil 
or criminal enforcement action against a provider, we will publish this information on our 
website after any representations and/ or appeals have been concluded. 

Matters of concern 

1. Mr Coulthard was assessed as being suitable for discharge on 18th December. 
He remained in an acute hospital setting for a further 4 weeks due to challenges in 
identifying a suitable care home. This was due the inquest was told to a shortage 
of suitable places and the Christmas period. The impact of this on Mr Coulthard 
was  that he  remained in an acute setting  when  the  inquest was  told  the care  he 
required would have been better delivered in a care home /nursing 
home setting. 

In addition, the inquest heard evidence that it meant that an acute bed required for 
other  patients  was  not  available  creating  delays  in  allocating  beds  to  patients 
requiring  admission.  The  inquest  was  told  that  significant  delays  of  this  nature 
occur on a regular basis and are often exacerbated over the Christmas period. 

We have given careful consideration to this point and have concluded that this, regretfully 
sits outside of CQC remit. We note that this report has also been sent to the Secretary of 
State  and  Greater  Manchester  Integrated  Care  and  believe  they  will  be  of  greater 
assistance in addressing this aspect of your concerns. 

2.  The  lack  of  effective  communication  between  the  discharging  team  and  the 
community teams meant that it was not understood if Mr Coulthard was on End of 
Life Care or for rehabilitation. The staff at the first home treated him as an End of 

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 Life  patient  /  palliative  care  patient  consequently  even  though  the  paperwork 
suggested  he  may  be  a  discharge  to  assess  patient.  As  a  consequence  he  was 
moved to another care home for rehabilitation although the evidence was that there 
was little purpose in the transfer. 

We  are  aware  that  the  registered  provider  for  Hilltop  Hall  has  reflected  on  the 
circumstances surrounding this case and identified some lessons learned to mitigate the 
risk of such occurrences and improve the service they provide.  

Prior to Mr Coulthard being accepted for admission to the home an “Assessment of Need” 
was completed via the hospital’s “trusted assessor” route, meaning that the provider did 
not  physically  assess  him  before  accepting  him  for  placement.  From  the  supported 
discharge referral form & Pathway 3 guidance document it is evident that Mr Coulthard 
was discharged on Pathway 3. Explanatory information provided within the referral form 
stated that Pathway 3, is often used for people who have life changing events, have been 
through other pathways multiple times, or are approaching the end of their life and may 
sadly be likely to quickly decline and will be likely to require long term bed-based care. In 
response to this guidance and Mr Coulthard’s presentation, staff at the home did not feel 
Mr Coulthard would benefit from rehabilitation and have acknowledged in response to this 
matter raised, that  there was a lack of professional dialogue to ensure clear directions 
and rationale for care and treatment pathways was agreed by relevant members of the 
multi-disciplinary team.  

To ensure staff at Hilltop Hall have all the relevant facts and are fully aware of a person’s 
health and care needs prior to admission, the registered provider has stated that they will 
in future carry out their own pre-admission assessments, rather than relying on trusted 
assessors.  

We  have  communicated  with  Greater  Manchester Integrated  Care  and  are  aware  that 
they are conducting their own investigation into the circumstances of this case. When this 
is  concluded  we  will  engage  in  further  dialogue  to  gain  further  understanding  of  any 
actions  they  believe  are  necessary  to  improve  communication  between  the  Trust  and 
community services. 

3. The inquest also heard evidence that the staff at the care home had queried what 
level  and  type  of  care  was  to  be  delivered  to  Mr  Coulthard  given  his  overall 
presentation.  However,  there  was  no  evidence  that  the  management  team  had 
sought to  clarify  the  position or  ensure  the  internal  documentation reflected  the 
correct position. 

As part of our processes, we are currently conducting a further assessment (under our 
new  Single  Assessment  Framework)  to  review  all  the  shortfalls  identified  at  the  last 
inspection and consider if there has been sufficient improvement. If we do not believe the 
registered provider has appropriately addressed the breaches of regulation to the extent 

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 that we can be confident that people are receiving safe care, we will continue with our 
enforcement activities.  

During  our  assessment,  with  reference  to  this  case  we  will  consider  the  following 
regulations, namely: Regulation 12 (i) which requires,  ‘where responsibility for the care 
and treatment of service users is shared with, or transferred to other persons, working 
with  such  other  persons,  service  users  and  other  appropriate  persons  to  ensure  that 
timely care planning takes place to ensure the health, safety and welfare of the service 
users’,  and  Regulation  17  (c)  which  requires,  ‘systems  or  processes  must  enable  the 
registered  person  in  particular  to  maintain  securely  an  accurate,  complete  and 
contemporaneous record in respect of each service user, including a record of the care 
and treatment provided to the service user and of decisions taken in relation to the care 
and treatment provided’. 

The registered provider for Hilltop Hall has reflected on the circumstances surrounding 
this case and identified some lessons learned to mitigate the risk of such occurrences 
and improve the service they provide which have been shared with HM coroner and CQC. 
We  will  consider  the  implementation  of  any  lessons  learned  as  part  of  the  current 
assessment  of  service  and  in  any  future  assessments  of  the  quality  and  safety  of  this 
service. 

4. The evidence before the inquest was that whilst in the community prior to his 
final  hospital  admission,  the  access  to  information  and  support,  from  tissue 
viability  and  district  nursing  teams,  to  care  for  and  treat  his  wounds  was  very 
limited. Better access to wound care would have reduced the risk of further wound 
deterioration in the community and reduced the risk of him requiring inpatient care 
for his wounds. However, the demands across GM on TVN and DN services made 
this difficult to achieve.  

We  have  considered  this point and  have  concluded  that,  this  regretfully  sits  outside  of 
CQC remit. We believe the Secretary of State and Greater Manchester Integrated Care 
will be of greater assistance in addressing this aspect of your concerns.  

We hope our response has outlined how CQC will respond to the concerns raised and 
how we will continue to monitor the service.  

Yours sincerely, 

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A8 
 
 
 
 
 
 
 
 
 
 
 
  
 Deputy Director of Operations  

Network North, CQC 

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A9

From 

Minister of State for Care   

39 Victoria Street   
London   
SW1H 0EU  

08 November 2024  

Our ref: 

HM Coroner Alison Mutch  
Coroner’s Court,  
1 Mount Tabor Street,  
Stockport  
SK1 3AG  

By email: 

Dear Ms Mutch   

Thank you for the Regulation 28 report of 24/09/2024 sent to the Secretary of State about 
the death of George Neville Coulthard. I am replying as the Minister with responsibility for 
Care.  

Firstly, I would like to say how saddened I was to read of the circumstances of Mr Coulthard’s 
death, and I offer my sincere condolences to their family and loved ones. The circumstances 
your report describes are concerning and I am grateful to you for bringing these matters to 
my attention.  

The  report  raises  concerns  over  the  shortage  of  suitable  places  in  care,  preventing  Mr 
Coulthard  from  receiving  the  appropriate  care  in  a  care  home/nursing  home  setting,  and 
creating delays in allocating beds to patients requiring admission. It also shows  a lack of 
communication between health and social care providers regarding the appropriate setting 
which Mr Coulthard should have been sent to, the adequate level type of care required for 
the patient, and the limited access to information and support regarding wound care.  

In preparing this response, my officials have made enquiries with NHS England to ensure 
we adequately address your concerns.  

Individuals should be discharged from hospital in a timely manner with the right care and 
support, to ensure better outcomes for patients and reduce the risk of medical complications. 
The Greater Manchester NHS Foundation Trust has provided a timeline and explanation for 
Mr Coulthard’s delayed discharge from Wythenshawe Hospital.  

Although Mr Coulthard was medically optimised, he was still receiving therapy input to work 
with  him  on  his  sitting  balance  from  18  –  23  December  2024.  Within  this  timeframe  Mr 
Coulthard also experienced a short period of feeling more unwell on 20 December 2023, 
where he was experiencing shivers which recovered after 24 hours.  He was also reviewed 

A1 
   
  
  
   
 
  
  
  
  
  
   
  
  
  
 by the plastics team on 23 December 2023 regarding his complex wound, discussed with 
, Plastics Consultant, to confirm that further management was via the tissue viability 
team with twice weekly dressing changes. The Integrated Team (IDT) would not have seen 
Mr  Coulthard  until  he  was  both  therapeutically  and  medically  optimised  as  the  therapy 
information can be crucial when placing someone.    

On 23 December 2023, Mr Coulthard was seen by the Specialist Discharge Nurse and he 
and  his  family  (his  partner  and  daughter)  were  spoken  to  in  regard  to  options  for  his 
discharge.   Later  that afternoon  a  best  interest decision  was  made  for 24-hour care. The 
assessment  was  not  submitted  until  27  December  2023  due  to  the  Bank  Holiday  which 
meant  that  the  commissioning  team  was  not  available  until  then. A  ‘discharge  to  assess’ 
referral  form  was  received  from  Wythenshawe  Hospital,  by  the  Transfer  of  Care  Hub,  at 
Stockport  NHS  Foundation Trust,  at  17:34  hours  on  Wednesday,  27  December  2023  via 
email. The referral was subsequently triaged at 08:28 hours, on 28 December 2023. It was 
noted on the referral form that Mr Coulthard lacked mental capacity. Further information was 
requested  via  e-mail,  on  28  December  2023,  seeking  evidence  of  Mr  Coulthard’s  Mental 
Capacity Act assessment and Best Interest decision outcome.  

On Friday, 29 December 2023, information was received back from Wythenshawe hospital. 
In line with commissioning arrangements, a senior multi-disciplinary team triage (Continuing 
Healthcare  Lead,  Adult  Social  Care  Lead  and  Transfer  of  Care  Hub  Operational  Lead) 
confirmed Mr Coulthard did require twenty-four-hour nursing provision and was, therefore, 
identified  as  being  on  Discharge  Pathway  3  (discharge  to  a  care  home  placement, 
coordinated  through  the  care  transfer  hub,  for  people  with  the  highest  levels  of  complex 
needs).   

Subsequently, the discharge form completed by Wythenshawe hospital was shared by the 
Transfer of Care Hub with four nursing homes to consider whether they would accept Mr 
Coulthard into their care. These were the four nursing homes within the Stockport locality 
with capacity that could meet Mr Coulthard’s needs at that time.    

Between 29 December 2023 and 5 January 2024, three of the four nursing homes declined 
to accept Mr Coulthard. On 9 January 2024, Hilltop Hall nursing home agreed to accept Mr 
Coulthard into their care pending confirmation of the Continuing Health Care (CHC) funding. 
On 10 January 2024, funding was confirmed with an agreed welcome date of 11 January  
2024. Mr Coulthard was discharged from Wythenshawe hospital and transferred to Hilltop 
Hall  nursing  home  on  11  January  2024.  Mr  Coulthard’s  referral  was  triaged  by  a  band  7 
nursing team lead within the Transfer of Care Hub to review current needs, establish the 
most appropriate discharge pathway and package of care to meet those needs. This was 
actioned within 48 hours including requiring the additional information.   

Looking at this case, the Greater Manchester NHS Foundation Trust agrees that, although 
it  can  take  time  to  complete  all  the  necessary  arrangements  for  a  safe  and  appropriate 
transfer of care for someone with complex needs, the time from a decision that Mr Coulthard 
was medically optimised (18 December 2023) to his actual transfer to Hilltop Hall Nursing 
Home (11 January 2024) was too long.  

The government recognises the need to do more to ensure that patients are discharged in 
a timely manner, and to the appropriate care setting, to allow for a more effective and quicker 
recovery, and prevent tragic medical complications such as those suffered by Mr Coulthard. 
This year, the NHS and local authorities are receiving £1 billion through the Discharge Fund 
to help them improve capacity for post-discharge support and reduce delayed discharges. 

A2 This  funding  is  pooled  via  the  Better  Care  Fund,  which  requires  integrated  care  boards 
(ICBs)  and  local  authorities  to  make  joint  plans  and  pool  budgets  for  the  purposes  of 
providing  more  joined-up  and  effective  care.  Every  acute  hospital  has  access  to  a  care 
transfer  hub.  These  hubs  bring  together  professionals  from  the  NHS  and  social  care  to 
manage  discharges  for  people  with  more  complex  needs  and  who  need  extra  support. 
Statutory  guidance  on  hospital  discharge  (updated  in  January  2024)  sets  out  how  local 
authorities  and  NHS  bodies  can  ensure  that  people  are  discharged safely  from  hospital  to  the 
most appropriate place and continue to receive the care and support they need, taking into account 
the legal duties in the Health and Care Act 2022.    

Regarding  the  lack  of  communication  between  the  discharging  team  and  the  community 
teams, the Greater Manchester NHS Foundation Trust agrees that there was little purpose 
in the transfer to Bramhall Manor, due to the rapid deterioration in Mr Coulthard’s condition 
and the fact that he did not benefit from the daily therapy intervention that the ‘Discharge to 
Assess’ therapy team assessed Mr Coulthard to require on 14 January 2024. As stated in 
section 82 of the Health and Care Act 2022, health and care systems and providers should 
work together to ensure that efforts to discharge individuals from hospital into social care 
are  joined  up  and  make  best  use  of  available  resources.  This  involves  communication 
regarding patients’ needs and providing accurate information to care providers.  

Concerning the matter that there was no evidence that the management team had sought 
to  clarify  the  position  to  ensure  the  internal  documentation  reflected  the  correct  position 
regarding the type of care required for Mr Coulthard, the team at Hilltop Hall acknowledge 
that they did not attend the hospital to assess Mr Coulthard. Such assessments enable a 
home  team  to  gain  a  clear  understanding  of  an  individual’s  current  care  needs  and 
circumstances.  The  Home  Manager  acknowledges  that  this  should  have  happened  and 
confirms  that  a  change  in  practice  resulting  from  this  case  has  been  that  pre-admission 
assessments are now always undertaken.  

Effective communication between health and care teams is vital for providing appropriate 
care  for  patients  and  facilitating  quick  recovery.  The  discharge  guidance  published  in 
January 2024 reflects the duty in the Health and Care Act 2004 for NHS bodies and local 
authorities  to  cooperate.  The  guidance  make  clear  that  local  areas  should  agree  the 
discharge  models  that  best  meet  local  needs  and  are  effective  and  affordable  within  the 
budgets available to NHS commissioners and local authorities.   

I hope this response is helpful and that it demonstrates that we are taking active steps to 
provide patients with the care that they need to prevent future deaths. Thank you for bringing 
these concerns to my attention.    

Yours sincerely,  

A3

E: 

Date: 25 November 2024 

Private & Confidential 

Ms Alison Mutch 
Senior Coroner  
Coroner’s Court 
1 Mount Tabor Street 
Stockport 
SK1 3AG 

Sent by email to: 

Dear Ms. Mutch 

Re: Regulation 28 Report to Prevent Future Deaths - George Neville Coulthard 

Thank you for your Regulation 28 Report dated 24 September 2024 regarding the sad death of George 
Neville Coulthard. On behalf of NHS Greater Manchester Integrated Care (NHS GM), We would like to 
begin by offering our sincere condolences to Mr. Coulthard’s family for their loss. 

Thank you for highlighting your concerns during the inquest which concluded on the 29 August 2024. 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.   

During the inquest you identified several causes for concern. I have investigated and my response 
outlines some background information and then specifically addressed each cause of concern. 

Background 

Mr Coulthard attended Trafford Urgent Care Centre on 24 October 2023 after a fall. He was seen with his 
daughter and had sustained an injury to his left lower leg and left hand.  At the time of the examinations, 
he was found to have superficial wounds over his shins. He had x ray of his left lower leg and left hand 
which did not show any fracture (break). His wound was cleaned dressed, and he was discharged home 
to be followed up by the district nurses. 

Mr Coulthard re-attended the Trafford Urgent Care Centre on 27 October 2023 with increasing pain and 
redness to his left lower leg wound (shin wound). He felt otherwise well.  At the time of examination, the 
left shin wound appeared swollen and erythematous (red) and suggestive of infected wound. With a likely 
diagnosis of an infected wound to his left shin (Cellulitis). A wound swab was taken (to check what kind of 
bacterial infection was present) and what antibiotics should be prescribed, and the wound was redressed. 

4th Floor, Piccadilly Place, Manchester  M1 3BN   
Tel: 0161 6257791  www.gmintegratedcare.org.uk 

A10 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Mr Coulthard was given antibiotics to take home for treatment of likely wound infection. The antibiotic given 
at the time was the right antibiotic as confirmed by the swab result.   

Mr Coulthard attended the Emergency Department at Wythenshawe Hospital on 8 November 2023. He 
was assessed with his daughter present. It was noted that over the previous two and a half weeks he had 
been rapidly deteriorating in terms of his clinical state  with reduced mobility and being unable to eat or 
drink well. He had been referred to the crisis team and to be assessed for having home modification. He 
had suffered an unwitnessed fall at home the night before and was found on the floor at 06:00 hrs on the 
morning of the attendance. He had tenderness to the right side of his chest and some tenderness over the 
region of his pelvis. He was prescribed and administered intravenous fluids, antibiotics and a CT of his 
head, chest, abdomen and pelvis was completed which did not show anything concerning. Given the above 
concerns he was admitted under the care of the medical team.   

Mr Coulthard remained in Wythenshawe Hospital receiving treatment for various medical conditions. On 
18 December 2023, in view of his ongoing physical deterioration with no realistic prospect of improvement, 
a multi-disciplinary team decision was made that Mr Coulthard’s new functional baseline would be hoist 
transfer  from  bed  to  chair.  He  was  also  considered  medically  optimised  and  discharge  planning  was 
initiated. Mr Coulthard remained stable, and plans were made for a transfer to a care home. 

I will now address each of the areas of concern as detailed within the Regulation 28 Prevention of Future 
Deaths Report: 

Mr  Coulthard  was  assessed  as  being  suitable  for  discharge  on  18  December  2023  .  he 
remained in an acute hospital setting for a further 4 weeks due to challenges in identifying 
a suitable care home. This was due, the inquest was told, to a shortage of suitable places 
and the Christmas period. The impact of this on Mr Coulthard was that he remained in an 
acute  setting  when  the  inquest  was  told  the  care  he  required  would  have  been  better 
delivered in a care home / nursing home setting. 

Although Mr Coulthard was medically optimised, he was still receiving therapy input to work with him on 
his sitting balance from 18 – 23 December 2024.Within this timeframe Mr Coulthard also experienced a 
short  period  of  feeling  more  unwell  on  20  December  2023,  where  he  was  experiencing  shivers  which 
recovered after 24 hours. He was also reviewed by the plastics team on 23 December 2023 regarding his 
complex wound, discussed with Mr Wong, Plastics Consultant, to confirm that further management was 
via the tissue viability team with twice weekly dressing changes. 

The  Integrated  Team  (IDT)  would  not  have  seen  Mr  Coulthard  until  he  was  both  therapeutically  and 
medically optimised as the therapy information can be crucial when placing someone.  

On 23 December 2023, Mr Coulthard was seen by the Specialist Discharge Nurse and he and his family 
(his partner and daughter) were spoken to regarding options for his discharge.  Later that afternoon a best 
interest decision was made for 24-hour care. 

The assessment was not submitted until 27 December 2023 due to the Bank Holiday which meant that the 
commissioning team was not available until then. 

A discharge to assess (D2A) referral form was received from Wythenshawe Hospital, by the Transfer of 
Care (ToC) Hub, at Stockport NHS Foundation Trust, at 17:34 hours on Wednesday, 27 December 2023 
via e-mail. The referral was subsequently triaged at 0The 8:28 hours, on 28 December 2023. It was noted 
on the referral form that Mr Coulthard lacked mental capacity. Further information was requested via e-

4th Floor, Piccadilly Place, Manchester  M1 3BN   
Tel: 0161 6257791  www.gmintegratedcare.org.uk 

A11 
  
 
 
 
 
 
 
 
 
 
 mail, on 28 December 2023, seeking evidence of Mr Coulthard’s Mental Capacity Act assessment and 
Best Interest decision outcome. 

On  Friday,  29  December  2023,  information  was  received  back  from  Wythenshawe  Hospital.  As  per 
commissioning arrangements, a senior multi-disciplinary team triage (Continuing Healthcare (CHC) Lead, 
Adult Social Care (ASC) Lead and Transfer of Care Hub (ToCH) Operational Lead) confirmed Mr Coulthard 
did require twenty-four-hour nursing provision and was, therefore, identified as being on a Discharge to 
Assess Pathway 3. The national definition1 of Pathway 3 refers to people being discharged from an acute 
hospital to a new residential or nursing home setting, for people who are considered likely to need long-
term  residential  or  nursing  home  care.  The  government  guidance  states  that  other  than  in  exceptional 
circumstances, no one should be discharged directly into a permanent care home placement for the first 
time without first giving them an opportunity to recover in a temporary placement before assessing their 
long-term needs. 

Subsequently,  the  D2A  form  completed  by  Wythenshawe  hospital  was  shared  by  the  ToCH  with  four 
nursing homes to consider whether they would accept Mr Coulthard into their care. These were the four 
nursing homes within the Stockport locality that were outside the Pathway 2 D2A commissioned beds, with 
capacity that could meet Mr Coulthard’s needs at that time.   

Between 29 December 2023 and 5 January 2024, three of the four nursing homes declined to accept Mr 
Coulthard. On 9 January 2024, Hilltop Hall nursing home agreed to accepting Mr Coulthard into their care 
pending  confirmation  of  the  Continuing  Health  Care  (CHC)  funding.  On 10  January  2024,  funding  was 
confirmed  with  an  agreed  welcome  date  of  11  January  2024.  Mr  Coulthard  was  discharged  from 
Wythenshawe hospital and transferred to Hilltop Hall nursing home on 11 January 2024. 

Mr Coulthard’s referral was triaged by a Band 7 nursing team lead within the ToCH to review current needs 
and establish discharge pathway and provision in community beds where needs could be met. This was 
actioned within 48 hours including requiring the additional information.  

Once a patient is deemed to be medically optimised (to be as well as can be achieved), the aim is either 
for the patient to be discharged to their home, or for arrangements to be put in place for transfer to an 
appropriate care setting, able to meet their needs at that time and to support rehabilitation where that is 
indicated. 

Looking at this case, I agree that the time from a decision that Mr Coulthard was medically optimised (18 
December  2023)  to  his  actual  transfer  to  Hilltop  Hall  Nursing  Home  (11  January  2024)  was  too  long. 
However,  as  explained above,  it  can  take  time  to  complete  all  the  necessary  formalities  to  progress  a 
complex discharge. 

You refer to information provided at the inquest suggesting that the festive period may have had an impact 
on  the  time  taken  to  secure  Mr  Coulthard’s  safe  discharge.  Whilst  accepting  that  this  was  a  complex 
discharge, and would have taken time to facilitate, the festive bank holiday did impact in that there was a 
period of three days where the discharge information was available but could not be processed, for which 
I sincerely apologise. 

In addition, the inquest heard evidence that it meant that an acute bed required for other 
patients  was  not  available  creating  delays  in  allocating  beds  to  patients  requiring 
admission. The  inquest was  told that  significant  delays  of  this nature  occur  on  a  regular 

¹Hospital discharge and community support guidance - GOV.UK (www.gov.uk) 

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 basis and are often exacerbated by the Christmas period.  

Whenever a patient is medically optimised and no longer in need of care in an acute hospital setting, the 
aim is for that individual to be discharged safely to their home, or to an appropriate place of care as soon 
as it can be safely facilitated. 

You refer to such delays occurring on a regular basis and often exacerbated by the festive period. The 
winter period generally is extremely busy with high numbers of patients entering the hospital and needing 
to be  admitted  for  care and treatment.  Whilst  every  effort  is made to appropriately manage the flow  of 
patients to free up beds, there are occasions when delays in discharge do impact on patient flow. This is 
regrettably not a scenario that is specific to the festive period as such challenges occur throughout the 
year, but particularly through the winter months. As a system we consistently review discharge processes, 
alternatives to hospital admission, and patient flow pathways. This is with a view to improving the patient 
experience and flow through all GM hospitals so that patients can receive the right care at the right time 
and in the right place. 

The  lack  of  effective  communication  between  the  discharging  team  and  the  community 
teams  meant  that  it  was  not  understood  if  Mr  Coulthard  was  on  end-of-life  care  or  for 
rehabilitation. The staff at the first home treated him as end of life / palliative care patient as 
a  consequence  even  though  the  paperwork  suggested  he  may  be  a  discharge  to  assess 
patient.  As a consequence he was moved to another care home for rehabilitation although 
the evidence was that there was little purpose in the transfer. 

The D2A referral form received on Wednesday, 27 December 2023, from Wythenshawe hospital, provided 
the following information (this was also further discussed with the discharging organisation): 

‘Pathway 3 - 24 hour nursing care under Discharge to Assess recommended.  

Capacity assessment had taken place, referral states fluctuating capacity – currently very sleepy a 
great deal of the time and has fluctuating capacity due to ongoing delirium. Tissue Viability Nurses 
management of lower limb wounds now chronic.  

Requires:  dynamic  mattress,  static  cushion,  2  hourly  repositioning.  Hoist  to  tilt  in  space  chair 
although very fatigued if sat out for long periods.’  

As is standard, good, practice, the D2A referral form was shared with the nursing homes in order for them 
to triage their patient admission and as part of their acceptance process. There was nothing in the referral 
to imply Mr Coulthard was at the end of his life. 

There would be an expectation that the nursing team on the discharging ward would provide a verbal and 
written handover to the nursing home at the time of discharge to promote continuity of patient care and to 
ensure that a patient’s needs at the time of discharge could still be met. 

The hospital team did provide information to Hilltop Hall in written form (Greater Manchester Supported 
Discharge Referral document) in addition to which the former Manager at Hilltop Hall did speak directly 
with  the  ward  team  and  based  on  the  information  provided,  confirmed  that  Hilltop  Hall  could  meet  Mr 
Coulthard’s needs, formally accepting him to the home as a discharge to assess resident.  

The referral document included a detailed medical history, medications and clearly set down current care 

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 needs.  The  document  advised  that  Mr  Coulthard  was  ‘very  sleepy  a  great  deal  of  the  time  and  had 
fluctuating capacity due to ongoing delirium’. On arrival to Hilltop Hall nursing home, Mr Coulthard was as 
described and staff at the home report being surprised that there was a plan for potential rehabilitation. 

On 14 January 2024, following admission to Hilltop Hall nursing home, a review was completed by a senior 
member of the D2A therapy team. On assessment, the therapist found Mr Coulthard’s needs to be different 
from the information on the original D2A referral; they felt that with additional therapy, to improve functional 
ability, there would be an opportunity for Mr Coulthard to return home. The placement at Hilltop Hall did 
not offer the daily therapy intervention that the therapist assessed Mr Coulthard to require. 

Therapist /  Assessor  recommended bed based  intermediate  care,  and  a  bed was sourced  at  Bramhall 
Manor nursing home, where daily therapy intervention was available. This decision was reached following 
a conversation with Mr Coulthard’s daughter who agreed the transfer to Bramhall Manor nursing home 
was  in  Mr  Coulthard’s  best  interest.  Mr  Coulthard  transferred  to  Bramhall  Manor  nursing  home  on  20 
January 2024.  

On  arrival  to  Bramhall  Manor,  Mr  Coulthard  was  noted  to  be  very  unwell,  and  it  was  immediately 
acknowledged that it was unlikely that he would benefit from rehabilitation. The GP saw Mr Coulthard on 
22 January 2024 at which point it was confirmed that he was sadly nearing the end of life. Appropriate 
anticipatory  medications  were  prescribed  to  ensure  Mr  Coulthard  was  as  comfortable  as  possible.  His 
health continued to deteriorate, and sadly he passed away at Bramhall Manor on 27 January 2024. 

I am satisfied that staff across the system did act in what they believed to have been Mr Coulthard’s best 
interest when they transferred his care to Bramhall Manor so that he could receive daily therapy input. 
However, the rapid deterioration in his condition and the fact that he did not benefit from such therapy does 
lead me to agree that there was little purpose in the transfer to Bramhall Manor.  

We strive to provide outstanding end of life care and have only one opportunity to get things right. In Mr 
Coulthard’s case, whilst I acknowledge that there was a delay in recognition that he was entering the end 
of life stage, I am satisfied that he did receive a high standard of care in his final days of his life. 

The inquest also heard evidence that the staff at the care home had queried what level and 
type of care was to be delivered to Mr Coulthard given his overall presentation. However, 
there  was  no  evidence  that  the  management  team  had  sought  to  clarify  the  position  to 
ensure the internal documentation reflected the correct position.  

The  ToC  Hub  is  a  health  and  social  care  team  that  co-ordinates  timely  discharges  by  linking  relevant 
services to prevent avoidable delays in the transfer of care of all patients with complex needs, in the care 
of an acute trust.  

The health and social care team decide / ensure the most appropriate discharge pathway a patient should 
be placed on, for them to achieve the best possible outcome. It recognises that a whole system approach 
is  key  to  reduce  and  prevent  un-necessary  delayed  transfer  of  care.  The  ToC  team  sought  further 
information with regards to Mr Coulthard’s needs to ensure the pathway he was placed on would provide 
the level of care he required.  

There  would  be  an  expectation  that  the  nursing  team  on  the  Wythenshawe  Hospital  discharging  ward 
would provide a verbal and written handover to the nursing home at the time of Mr Coulthard’s discharge, 
to promote continuity of patient care and to ensure that a patient’s needs at the time of discharge could 
still be met. The team at the Nursing Home would ensure that care / nursing needs could still be met. 

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A14 
  
 
 
 
 
 
 
 
 
 
 The team at Hilltop Hall acknowledge that they did not attend the hospital to assess Mr Coulthard. Such 
assessments enable a home team to gain a clear understanding of an individual’s current care needs and 
circumstances. The Home Manager acknowledges that this should have happened and confirms that a 
change  in  practice resulting  from  this  case  has  been  that  pre-admission  assessments  are  now  always 
undertaken. 

The evidence before the inquest was that whilst in the community prior to his final hospital 
admission the access to information and support, from tissue viability and district nursing 
teams, to care for and treat his wounds was very limited. Better access to wound care would 
have reduced the risk of further wound deterioration in the community and reduced the risk 
of him requiring inpatient care for his wounds. However, the demands across GM on TVN 
and DN services made this difficult to achieve. 

On  31  October  2022,  Mr  Coulthard’s  daughter  telephoned  the  Single  Point  of  Access  requesting  a 
community nursing visit, as her father had a wound to his right big toe. A domiciliary visit was arranged for 
the following day and domiciliary wound care visits continued; the wound was noted to be healing well. 
Domiciliary wound care visits continued from the community team and then Mr Coulthard was transferred 
to  the  Stockport  Treatment  Room  service  which  he  visited  to  have  his  wound  care  treatment.  It  is 
documented the toe wound had healed and Mr Coulthard was discharged from community services back 
to own private podiatrist, on 3 April 2023.  

There was no further contact with Mr Coulthard, until on 24 October 2023, when Mr Coulthard was re-
referred to the community nursing service as he had fallen and sustained wounds to both his legs. A visit 
was booked for 27 October 2023 as per referral request, Mr Coulthard was required to attend a hospital 
appointment on this date, therefore, the planned visit was rearranged for 29 October 2023. Community 
nurses commenced visits to redress wounds to both Mr Coulthard’s shins. On 3 November 2023, a Tissue 
Viability Nursing (TVN) service referral was completed. Community nursing wound care and venepuncture 
visits continued to be scheduled. On 6 November 2023, there was a virtual review by a TVN and a dressing 
plan regime agreed. Wound care continued by community nurses up until Mr Coulthard was admitted to 
hospital, on 8 November 2023, following a further fall. Mr Coulthard was, therefore, discharged from the 
community  nursing  service  at  that  time.  When  a  patient  is  admitted  into  a  hospital,  it  becomes  the 
responsibility of the ward staff to care for nursing needs, with specialist input requested by the ward staff 
as required. 

I hope the above addresses the concerns raised and that you are assured that as a system we continue 
to consistently review our admission and discharge processes to ensure that GM patients can access care 
in our acute hospitals when they need to. 

Best wishes 

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