Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0385, written 29 Jul 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Jul 2025 |
|---|---|
| Reference | 2025-0385 |
| Deceased | Leslie Thompson |
| Coroner | Chris Morris |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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 THIS REPORT IS BEING SENT TO: The Secretary of State for Health and Social Care CORONER I am Chris Morris, Area Coroner for Greater Manchester (South). 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 20th March 2025, Alison Mutch OBE, Senior Coroner for Manchester South opened an inquest into the death of Leslie Thompson who died at Tameside General Hospital, Ashton-under-Lyne on 20th February 2025, aged 94 years. The investigation concluded with an inquest which I heard on 16th July 2025. The inquest determined Mr Thompson died as a consequence of: 1a) Traumatic acute on chronic subdural haematoma II) Dementia, Frailty of old age, Anticoagulated Atrial Fibrillation, Heart failure At the end of the inquest, I recorded a conclusion of Accident CIRCUMSTANCES OF THE DEATH Mr Thompson died on 20th February 2025 at Tameside General Hospital Ashton-under-Lyne as a consequence of a head injury sustained in a fall in hospital against a background of a chronic subdural haematoma and multiple complex health Problems 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 MATTER OF CONCERN is as follows. Mr Thompson sustained the fall in hospital which ultimately led to his death at a point in time where he had been assessed as medically fit for discharge, but was awaiting a physiotherapy assessment. At inquest, the court heard evidence that this hospital (in common with many others) does not have core physiotherapy services operating at evenings and weekends. I am concerned as to the effects of this in terms of delays to discharge, and the resultant exposure to risk of patients for whom an acute hospital environment is not most suitable. 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 23rd September 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner, together with Mr Thompson’s widow and the hospital’s legal representative. I have also sent a copy to the Care Quality Commission, 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: 29th July 2025 Signature: Chris Morris, Area Coroner, Manchester South.
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 Care 39 Victoria Street London SW1H 0EU 19 September 2025 HM Area Coroner Chris Morris Coroner’s Court, 1 Mount Tabor Street Stockport SK1 3AG Dear Mr Morris, Thank you for the Regulation 28 report of 29 July 2025 sent to the Secretary of State about the death of Mr Leslie Thompson. I am replying as the Minister with responsibility for hospital discharge. First, I would like to say how saddened I was to read of the circumstances of Mr Thompson’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. This report raises concerns regarding the poor availability of core physiotherapy services in hospitals, particularly on evenings and weekends, and the impact this can have on hospital discharge delays. You are right to identify the increased risk to patients who are medically ready for discharge caused by such delays, and this government is committed to addressing this issue and ensuring that people do not spend longer than necessary in hospital. To achieve this, we are strengthening partnerships between the NHS and social care to ensure patients receive the support they need for timely and effective hospital discharge. This is part of the wider shift of care towards prevention, community-based and digitally enabled care outlined in the 10 Year Health Plan published this summer. To facilitate this collaborative approach, every acute hospital has access to a care transfer hub. These hubs bring together health service, social care, the voluntary sector and housing to coordinate complex discharges and ensure patients receive the most appropriate care in the right setting at the right time. These hubs are expected to operate seven days a week to ensure that delays in coordinating hospital discharges are minimised. Systems should therefore seek to optimise the operating hours of the hub by ensuring rotas allow for sufficient cover to facilitate necessary weekend discharges, and there is appropriate cover from pharmacy and hospital transport services during the working hours of the hub. This should mitigate instances where patients experience discharge delays caused by internal hospital processes, which was a priority set out in the Urgent and Emergency Care Plan for 2025/26. Furthermore, the Better Care Fund (BCF) is a key part of our plan to address discharge delays, especially where they are caused by a lack of a necessary service such as physiotherapy. The BCF supports Integrated Care Boards and local authorities to deliver joined-up health and social care, and this year, the BCF will provide £9 billion to help ensure patients receive appropriate and timely care in the right place, with shared accountability for discharge planning. Starting in the financial year 2026/27, we will reform the BCF to ensure consistent joint NHS and local authority funding for those services that are essential for integrated health and social care, such as hospital discharge, intermediate care, rehabilitation and reablement. Thank you for bringing these concerns to my attention. I hope this provides reassurance that we are taking meaningful action to address these issues and strengthen services relevant to hospital discharge across the country. Yours sincerely, MINISTER OF STATE FOR CARE
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