Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0094, written 19 Feb 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Feb 2025 |
|---|---|
| Reference | 2025-0094 |
| Deceased | Kenneth Clayton |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Tameside and Glossop Integrated Care NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Secretary of State of The Department of Health and Social Care 1 CORONER I am Alison Mutch , senior coroner, for the coroner area of Manchester South 2 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. 3 INVESTIGATION and INQUEST On 11th September 2024 I commenced an investigation into the death of Kenneth James CLAYTON. The investigation concluded at the end of the inquest on 27th January 2025. The conclusion of the inquest was NARRATIVE: Died from the complications of an unobserved fall that occurred in the Emergency Department during a prolonged wait for an inpatient bed. The medical cause of death was 1a) Bronchopneumonia 1b) Neck of Femur Fracture (operated on) 1c) Fall II) Frailty, Vascular Dementia, Acute Kidney Injury. 4 CIRCUMSTANCES OF THE DEATH Kenneth James Clayton was taken to Tameside General Hospital after two falls at his home address. He was assessed as requiring inpatient admission to a medical ward. Whilst waiting for an inpatient bed to become available he had an unobserved fall in the Emergency Department. He was found to have fractured his neck of femur and was operated on. Post operatively he deteriorated and developed complications from the fracture and operation. He died at Tameside General Hospital on 23rd August 2024. 5 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 could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – 1. The inquest heard evidence that a key factor in the fall was the prolonged time Mr Clayton was in the Emergency Department waiting for a bed to become available on a ward. The evidence was that he had been in the emergency department for about 8 hours when he fell. The inquest was told that the design of an Emergency Department is not suited to a need for prolonged observation of high falls risk patients. In addition generally patients are cared for on hospital trolleys which cannot be lowered in the way a hospital bed can be which further increases the risk of falls. 2. Prolonged waits in Emergency Department were on the evidence given to the inquest not unusual. As an example the court was told that on the morning the inquest was heard there were patients who had been waiting 40 hours for a bed on a ward. 3. The inquest was told that the primary reason for the challenges in moving patients through the Emergency Department was availability of beds. The evidence given was that the main challenge in freeing up beds was delayed discharge of patients who were medically ready for discharge but who needed a care package or a care home place to facilitate a safe discharge. 4. The inquest was told that for patient safety it was important, that whilst there were delays in ED throughput of patients, that a robust falls risk management system was in place. Tameside Hospital had put additional measures in place to manage falls risk in ED in a more consistent way but it was unclear what steps were in place nationally to manage falls risk in a consistent way in Emergency Departments. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and/or your organisation have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 16th April 2025. 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following interested Persons the son of Mr Clayton on behalf of the family, Tameside General Hospital 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. They may send a copy of this report to any person who they believe 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. 9 Alison Mutch HM Senior Coroner 19/02/2025
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Minister of State for Health (Secondary Care) 39 Victoria Street London SW1H 0EU 25 April 2025 Our ref: Alison Mutch Senior Coroner for Greater Manchester South. His Majesty’s Coroner’s Office, 1 Mount Tabor Street, Stockport SK1 3AG By email: Dear Ms Mutch, Thank you for the Regulation 28 report of 19 February 2025 sent to the Department of Health and Social Care about the death of Kenneth James Clayton. I am replying as the Minister with responsibility for urgent and emergency care. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Clayton’s death, and I offer my sincere condolences to his 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 regarding Emergency Department waiting times and patient care at Tameside and Glossop Integrated Care NHS Foundation Trust (TGFT). In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns. I am assured by NHS England that TGFT is implementing an Urgent & Emergency Care Improvement Programme, which focuses on patient flow and discharge. The programme is entering its second year from April 2025, and significant achievements include: • There are now 47 patients with a ‘No Criteria to Reside’ status. This is under the trust’s trajectory number of 50, having previously been over 100. This means that patients who are medically fit for discharge are being discharged to the right place much quicker therefore releasing hospital bed capacity. • An additional ward was opened in November 2024, which includes a discharge lounge. This supports increase in patient flow by caring for those ready for discharge who are waiting for medication and transport. The Government is clear that patients should receive the highest standard of service and care from the NHS. We acknowledge that urgent and emergency care performance has failed to deliver that standard in recent years. We have been honest about the challenges facing the NHS and we are serious about tackling the issues; however, we must be clear that there are no quick fixes. I would like to assure you we are committed to continuing to improve services to ensure patients can access the right care first time, only visiting A&E when necessary, and returning waiting times to the NHS constitutional standard where at least 95% of patients in A&E will be admitted, transferred or discharged within 4 hours. As a first step, in the Autumn Budget, the Government announced an extra £22.6 billion in day-today spending in 2025/26 for the NHS compared to 2023/24. An additional £3.1bn further capital investment over 2 years will provide the highest real-terms capital budget since before 2010. We recognise that investment alone won’t be enough and are determined that it must go hand in hand with fundamental reform. On 5 December 2024, the Government published the Plan for Change (available here: https://www.gov.uk/government/publications/plan-for-change), that set the mandate for the direction of change with clear milestones in five national missions, including building an NHS that is fit for the future. On 30 January 2025, the Government published ‘Road to recovery: the government's 2025 mandate to NHS England’, that clearly set out delivery instructions for the NHS through the prioritisation of five key objectives aimed at driving reform within the NHS. Improving A&E and ambulance wait time was a prioritised objective in the mandate to specifically address the current challenges facing urgent and emergency care. On the same day NHS England published the 2025-26 planning guidance that contained the operational delivery detail for local NHS systems. The planning guidance included an implementation target for improving A&E waiting times compared to 2024/25, with a minimum of 78% of patients seen within 4 hours in March 2026. The NHS will focus on delivering the following range of practical actions to improve performance in 2025/26: • increasing the proportion of patients seen, treated and discharged in 1 day or less using the principles of same day emergency care (SDEC) • optimising the urgent care offer to meet the needs of their local population, including the use of urgent treatment centres (UTCs) increasing the percentage of patients discharged by or on day 7 of their admission • • working across the NHS and local authority partners to reduce average length of discharge delay in line with the Better Care Fund (BCF) policy framework. Later in the Spring, to accompany the additional investment in the NHS, the Government will publish a 10-Year Health Plan which will set out the radical reforms for the NHS. The health plan will focus on ensuring three big reform shifts in the way our health services deliver care. First, from ‘hospital to community’ to bring care closer to where people live. Second, from ‘analogue to digital’ with new technologies and digital approaches to modernise the NHS, and third from ‘sickness to prevention’ so people spend less time with ill-health by preventing illnesses before they happen. The reforms will support putting the NHS on a sustainable footing so it can tackle the problems of today and the future. In addition, we will shortly set out further actions to be taken during 2025-26 to support improvements to urgent and emergency care performance this year. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, MINISTER OF STATE FOR HEALTH
See every Prevention of Future Deaths report matching Tameside and Glossop Integrated Care NHS Foundation Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.