Charles Daniels

Our ref: 
Your ref: 

PRIVATE AND CONFIDENTIAL 

Ms Jacqueline Devonish 
HM Senior Coroner 
Cheshire Coroner’s Service 
Museum Street 
Warrington, Cheshire 
WA1 1JX 

Ref: Mr Charles Henry DANIELS 

Dear Ms Devonish 

Karen James, OBE 
Oak House  
Stepping Hill Hospital 
Poplar Grove 
Stockport 
Cheshire 
SK2 7JE 

Tel: 0161 419 5000 

30 October 2024

Email: 

Further  to  the  inquest  you  held  on  29  August  2024  in  to  the  death  of  the  late  Mr  Charles 
Daniels, I am writing to you at your request for further information in relation to three matters 
of  concern  you  have  raised.  I  have  asked 
,  Associate  Medical  Director  for 
, Matron for Ward B5 at the time of Mr Daniels’ admission to 
Medicine and 
review your concerns. The Trust have also liaised with Patient Transfer Service (PTS) who 
transported Mr Daniels. 

I will address your concerns in turn: 

1)  Record  keeping  by  the  nursing  team  at  Stepping  Hill  Hospital  did  not  record  the 
fluctuations  in  presentation  relevant  to  the  diagnosis  of  intracranial  hypotension  or  to 
enable or confirm a review of his condition prior to discharge. 

  has  stated  that  intracranial  hypotension  is  commonly  associated  with  a 
headache that becomes severe when the patient is upright and disappears when the patient 
is laid flat. Nursing staff have documented that Mr Daniels did not complain of any pain and 
particularly  no  headaches  in  the  last  few  days  prior  to  his  discharge  from  Ward  B5  on  6 
March 2024.  

It is noted however that Mr Daniels did have fluctuating assistance needs. On 26 February 
2024 the therapy assistant documented that Mr Daniels had taken the assistance of three to 
mobilise  him  to the  chair  and  that  he  appeared to  be  leaning  a  little.  He was  subsequently 
reviewed by one of the medical team, a clinical assessment undertaken and no further action 
required.  He  was  again  seen  by  the  therapy  team  two  days  later  on  28  February  2024, 
where they have documented that Mr Daniels was mobilising with the assistance of one. The 
nursing entries within the patient record document that Mr Daniels required variable levels of 
assistance on 5 March 2024 from assistance of one with a frame to assistance of two prior to 
his  discharge.  We  therefore  recognise  that  Mr  Daniel’s  presentation  with  regard  to  his 
mobility did fluctuate throughout admission.   

’s  has  further  reviewed  the  record  and  has  confirmed  that  Mr  Daniels’  vital 
observations did not warrant any escalation to the medical team at any point from 4 March 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 2024  until  his  discharge  on  6  March  2024  and  in  line  with  policy  he  was  therefore  not 
escalated for review prior to discharge. 

  would  like  to  confirm  that  a  patient  who  is  deemed  medically  optimised  awaiting 
transfer (MOAT) and is stable does not require daily medical review, and certainly not by a 
consultant.  By  definition  if  MOAT  a  patient  is  deemed  to  have  no  requirement  to  be  in  an 
acute hospital bed and the only reason they remain admitted is due to a delay in being able 
to move them to a more appropriate location e.g. their own home or a care home. Wards at 
Stockport  NHS  Foundation  Trust  have  white  board  rounds  Monday  to  Friday  where  any 
change  in  condition  for  a  patient  would  be  escalated  and  discussed  and  would  lead  to  a 
senior  review  if  required.  This  provides  senior  oversight  for  all  patients.  Likewise  a  senior 
review can be requested out of hours if necessary. 

In  Mr  Daniels’  case  he  was  first  documented  as  being  MOAT  and  in  need  of  discharge 
planning  on  14  February  2024.  There  are  then  12  medical  reviews  which  all  deemed  Mr 
Daniels MOAT and for discharge planning between 15 February and 4 March 2024. As per 
Matron Evans’ review no further reviews took place between 4 to 6 March as observations 
did not report any reason for this to take place. We hope our review provides assurance with 
regards to this. 

2)  Neither  the  discharging  nurse  nor  North  West  Ambulance  Service  personnel  attending 
Stepping Hill on 6 March 2024, for the purposes of his discharge home, appear to have 
alerted  a  doctor  to  the  significant  deterioration  in  Mr  Daniels’  condition  since  last 
assessed by a doctor on 4 March. 

On the day of discharge, the Ward Sister recalls that Mr Daniels required the assistance of 
three to transfer but due to his variable requirements for assistance with mobility, this did not 
appear unduly out of character.  

Mr Daniels’ national early warning score (NEWS) had been scored at zero from the evening 
of 31 January 2024 throughout the admission until his discharge on 6 March 2024. Therefore 
the team caring for Mr Daniels’ did not identify a significant deterioration, nor that the score 
required escalation for review. 

The  Trust  have  contacted  Patient  Transfer  Service  (PTS)  who  provided  transport  for  Mr 
Daniels  from  Ward  B5  on  his  discharge to  home.  Unfortunately for this  type  of  transfer  the 
crew  do  not  record  any  written  records  of  the  transfer.  However,  the  Group  Head  of 
Customer Experience has checked their incident management system and confirmed that no 
incident related to the transfer was recorded. It would be expected that if the crew had any 
concerns regarding the transfer, including a patient who presented as too poorly for transfer, 
then this would be incident reported.  Patient Transfer Service has also confirmed that two 
crew  members  transported  Mr  Daniels,  however  the  service  has  not  been  able  to  provide 
any additional information following our request.  

3)  He arrived home by ambulance to his family in physically poor condition and clearly very 
unwell, on a stretcher in a hospital gown and incontinent, causing considerable distress to 
the family,  particularly  after  a  nurse,  the  paramedics  and  his  carer  questioned  how  they 
would cope with his care at home. 

  has  reviewed  the  nursing  notes  for  Mr  Daniels  from  5  March  2024  and  can 
confirm  that  there  is  no  documentation  to  show  that  the  nursing  staff  felt  that  Mr  Daniels’ 
condition  had  deteriorated  on  that  day.  However,  following  concerns  raised  by  Mr  Daniels’ 
  informed the  therapists  on the  ward  that  it  had  taken 
family  on  6 March  2024 
three  staff  to  assist  Mr  Daniels  on  his  discharge  home.  Given  that  he  had  been  mobilising 
with  the  assistance  of  one  member  of  staff  prior  to  this,  we  should  have  considered  an 

 
 
 
 
 
 
 
 
 
 
 
 
 additional  therapy  assessment  prior  to  discharge.  We  apologise  that  this  was  not 
considered. 

. 
  has  further  investigated  by  speaking  to  Ward  Sister 
Unfortunately, due to the time since this event the ward nursing staff are unable to recollect 
any discussion with family members relating to how Mr Daniels would cope at home. 

  wishes  to  apologise  for  the  distress  this  comment  caused  to  the  patient  and 
family, but would like to reiterate that if staff had any concerns regarding the discharge, that 
this would have been postponed. 

 would like to apologise that Mr Daniels was sent home in his hospital gown and 
not  in  his  own  clothing,  as  this  is  something  which  the  ward  always  encourages.  The 
‘Dressed  is  best’  campaign  is  encouraged  across  the  Trust  and  compliance  is  monitored 
through  monthly  audits  and  reported  via  the  Lead  Nurse’s  report  at  the  Divisional  Quality 
  would  like  to  apologise  for  the  poorly  condition  in  which  Mr  Daniels’ 
Group. 
family describe he arrived back home in. She is confident that had his condition appeared as 
described prior to discharge, then the discharge process would have been delayed and she 
would have ensured that Mr Daniels had a medical review.  

’s  has  also  reviewed  Mr  Daniel’s  medical  record  in  relation  to  continence. 
Nursing  staff  have  documented  that  Mr  Daniels  was  continent  and  was  using  urine  bottles 
whilst  in  hospital  and  so  no  continence  aids  were  deemed  necessary  for  transportation 
’  confirms  that  Mr  Daniel’s  was  clean  and  dry  prior  to  discharge 
purposes. 
home and the team are unable to explain why this occurred following discharge.  

I  would  again  like  to  express  my  apologies  to  Mr  Daniel’s  family  in  relation  to  concerns 
relating to Mr Daniel’s discharge.  I would however like to provide assurance that a thorough 
review  of  his  notes  has  been  undertaken  and  that  following  this  it  is  considered  that  Mr 
Daniel’s  medical  presentation,  at the  point  of  discharge,  was  appropriate  for  Mr  Daniel’s  to 
discharge to take place.    

I trust that the above addresses your concerns. Please do not hesitate to contact the Trust if 
you require any further information. 

Yours faithfully 

Chief Executive