Prevention of Future Deaths reports
Regulation 28 report to prevent future deaths, reference 2025-0616. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Reference | 2025-0616 |
|---|---|
| Deceased | John Alston |
| Coroner | Kate Bisset |
| Coroner area | Lancashire and Blackburn with Darwen |
| Category | Care Home Health 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.
Lancashire & Blackburn with Darwen Coroners Regulation 28: REPORT TO PREVENT FUTURE DEATHS (pursuant to Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. NHS England 1. Coroner I am Kate Bisset, Area Coroner for Lancashire and Blackburn with Darwen. 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 the 8th of November 2022 the Coroner’s Office was notified of the death of John Graham Alston and an investigation commenced into his death. There was an initial delay whilst Police and the CQC considered whether a criminal prosecution was required but confirmation of no criminal changes and thus a reversion to a Coronial investigation resumed on the 13th June 2024. An inquest was opened and adjourned on the 28th of February 2023 and a final inquest took place between the 2nd and 5th of December 2025. The conclusion of the inquest was that: “John Graham ALSTON, who was better known as Graham ALSTON, died on the 8th of November 2022 at the St Catherine's Hospice, Lostock Hall, Preston as a consequence of injuries he sustained after he was punched to the face on the 2nd November 2022. Mr ALSTON was a resident at a specialist dementia care home due to a diagnosis of dementia. Whilst at that home, he was punched to the face by another resident who was significantly younger than Mr ALSTON 1 and had impaired cognition. The other resident had been inappropriately placed at the care home, in part due to incomplete assessment documents being shared with the home via an unsuitable discharge pathway. Concerns were quickly raised regarding the suitability of the resident's stay at the home but a new placement was not able to be identified. On the 2nd November 2022, at least three staff members were with the resident when Mr ALSTON entered the communal space and touched the resident who responded with violence towards Mr ALSTON. None of the staff members observed Mr ALSTON enter the room or approach the resident and so no staff member prevented the incident from occurring. It was known that the resident presented a risk of violence to other residents and had used violence against Mr ALSTON in the past." 4. Circumstances of the death Mr Alston was a 70 year old man who had a diagnosis of dementia which sometimes resulted in challenging behaviours. By early 2020 he was resident in a challenging behaviours unit of a residential care home to support his needs. In August of 2022 another resident, , moved into the home. He was a much younger male with an acquired brain injury and he displayed significant aggression against staff, residents and on a number of occasions, Mr Alston himself. The care home quickly identified that the placement was not suitable but no alternative placement was identified. There were delays in commencing a search for an alternative placement due to confusion about which commission area had responsibility for . entered a dining room with his 1:1 as he often held hands with others. On the 2nd of November 2022, carer. At least two other members of staff were present in the dining room. Mr Alston entered the dining room, unwitnessed by staff, approach and took hold of reacted by punching Mr Alston twice causing a bleeding nose. Staff intervened to separate the men and Mr Alston was assessed. He was initially believed to be not seriously hurt but later demonstrated neurological symptoms and had a seizure. He was taken to hospital where investigations revealed he had an unsurvivable brain bleed. Mr Alston was transferred to a hospice where he died on the 8th of November 2022. 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 will occur unless action is taken. In the circumstances it is my statutory duty to report to you. 2 The MATTERS OF CONCERN are as follows: 1. had been moved to the Lancashire ICB commissioning area by a Bolton (Greater Manchester) commissioning service due to the existence of care home with a place for him (care home one). His placement at that care home broke down and he was taken to the local accident and emergency department. some time and was then discharged to care home two where the circumstances resulted in Mr Alston's death occurred. remained in hospital for It was quickly apparent that care home two could not meet needs and this was escalated to the Lancashire ICB. However the care home had first been directed to the Bolton (Greater Manchester) authorities by the local hospital. There was confusion as to which ICB was the commissioning body. This resulted in work being carried out by Lancashire ICB which ought to have been completed by the Bolton (Greater Manchester) ICB and a delay in commencing a search for an alternative and safe placement for There were also difficulties in sharing information for discharge processes because it was unclear which area or from where had come. This inquest concluded that due to the complexity of presentation, the delays due to confusion about ICB identification did not contribute to Mr Alston's death occurring at the time at which it did. However, I am concerned that there may be other cases where inaccurate or unknown information about which commissioning service is responsible for a resident can result in delays to accessing increased funding for support, services or more suitable placements. I am concerned that these delays may result in future deaths and that a clearer system is necessary to identify at an early stage and appropriately communicate that to a home who accepts a resident. I am concerned that determination of funding ICB arises on a reactive basis when additional care or changes are required and thus the time taken to resolve the issue delays necessary care or changes when proactive determination of the issue before problems arise ought to be possible. 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 3 7. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by the 30th of January 2026. I, the Coroner, may extend the period and to take into account the likely disruption to services caused by Christmas breaks, I extend that period of response to the 14th of February 2026 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 Family of Mr Graham Alston; ; The Family of The Hulton House Care Home Lancashire ICB Greater Manchester ICB Lancashire Teaching Hospitals Trust The Department of Health and Social Care 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. She may send a copy of this report to any person who she 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 9. 05.12.2025 Kate Bisset Area Coroner for Lancashire and Blackburn with Darwen 4
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.
Kate Bisset
Area Coroner for
Lancashire and Blackburn with Darwen
Coroner’s Court
2 Faraday Court
Faraday Drive
Preston
Lancashire
PR2 9NB
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
17th February 2026
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – John Graham Alston who
died on 8th November 2022.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 5th
December 2025 concerning the death of John Graham Alston (better known as
Graham Alston) on 8th November 2022. In advance of responding to the specific
concerns raised in your Report, I would like to express my deep condolences to
Graham’s family and loved ones. NHS England is keen to assure the family and
yourself that the concerns raised about the circumstances relevant to Graham’s death
have been listened to and reflected upon.
I am grateful for the further time granted to respond to your Report, and I apologise for
any anguish this delay may have caused to Graham’s family or friends. I realise that
responses to Coroners’ Reports can form part of the important process of family and
friends coming to terms with what has happened to their loved ones, and I appreciate
this will have been an incredibly difficult time for them.
Your Report raises concerns with the following:
1. Difficulties in sharing information for discharge processes between Integrated
Care Boards (ICBs) when a person has moved to a new area. Inaccurate or
unknown information about which commissioning service is responsible for a
patient or care home resident can result in delays to accessing increased
funding for support, services and more suitable placements.
2. The determination of the responsible funding ICB arises on a reactive basis
when additional care or changes are required, rather than there being a
proactive determination.
Determining the ICB with commissioning responsibility
NHS Greater Manchester (GM) ICB’s Head Nurse for Quality and Personalised Care
has reviewed your Report and provided NHS England with further information around
this case. NHS Funded Nursing Care (FNC) is the funding provided by the NHS to
care homes to support the provision of nursing care by a Registered Nurse for those
assessed as eligible (with reference to the National Framework for NHS Continuing
Healthcare and NHS Funded Nursing Care 2022).
As per NHS England’s ‘Who Pays’ guidance, when an individual is eligible for FNC but
has moved out of the area, the FNC is transferred to the receiving out of area ICB that
the patient resides in and has a registered GP in. Exceptions apply where the
individual is in receipt of Continuing Healthcare (CHC) or where they have been
detained under the Mental Health Act. In this case, the FNC was transferred from GM
ICB to Lancashire and South Cumbria (LSC) ICB and accepted. LSC ICB was
responsible for the care home resident, Mr Wright, from 17 April 2022.
As confirmed by GM ICB’s Head Nurse, the social care aspect of an individual’s care
is commissioned by either the individual patient (dependent on financial assessment,
determined by the Local Authority) or contributed to by the Local Authority. It is the
Local Authority that typically commissions the majority of the placement (depending
on an individual’s health and social care needs and the type of funding in place) and
sets up the contract with the provider.
In Mr Wright’s case, it is understood that he remained an ordinary resident of Bolton
despite being moved to Preston with health funding in place, which may have
contributed to the confusion around the responsible commissioner when Mr Wright
was discharged from hospital to Care Home Two.
Appendix 1 of the ‘Who Pays’ guidance sets out the principles where there is any
disagreement about commissioning responsibility between ICBs and the formal
dispute resolution process that should be followed where this cannot be resolved
locally. This includes escalating disagreements to NHS England’s regional or national
teams.
Ultimately, the ‘Who Pays’ guidance is an essential document for ICBs in setting out
the framework for establishing which NHS commissioner has responsibility for an
individual’s NHS care and should be referred to by ICB’s at the earliest opportunity.
Information sharing between ICBs
The concerns raised in your Report around the difficulties in information sharing and
the delays in identifying the responsible ICB would be best addressed by the ICBs
involved, rather than NHS England. In particular, it would be for the ICBs to comment
upon how they could implement a clearer system to appropriately communicate the
position around commissioning responsibility to care homes, where a new resident
has moved areas.
GM ICB’s Head Nurse has advised that they have been unable to locate any
correspondence on their system regarding Mr Wright from the period relevant to this
case.
NHS England’s North West regional colleagues have also contacted LSC ICB who
outlined the learning that has taken place as a result of this case. This included
commissioning and publishing a Safeguarding Adults Review (SAR) by the Lancashire
Safeguarding Adults Board (LSAB).
To drive forward learning, a task and finish group was convened, and a multi-agency
action plan was put in place. LSC ICB took the opportunity for wider learning in respect
of this case by reviewing the processes both for receiving and transferring residents
in/out of area. As a result, LSC ICB have changed and refined processes to ensure
that all relevant information is shared with the receiving ICB when transferring a
Lancashire patient’s funding.
LSC ICB is committed to working with receiving ICBs to ensure that the package is
stable and meets the needs of the patient before transfer. As part of this review
process LSC ICB now make clear to the Regulated Care Provider when responsibility
has transferred to them in order to eliminate confusion on the commissioner of the
package of care. The All Age Continuing Care teams will meet with transferring ICBs
as required. Weekly case progression meetings are held internally to allow progress
updates for all cases being transferred and follow up of outstanding actions. LSC ICB
continues to identify patients who are transferred to Lancashire providers with unstable
packages of care.
An assurance audit of the SAR actions is to be undertaken by the Quality Performance
subgroup of the LSAB. Work is scheduled for the coming quarter and Quarter 1
2026/27.
I would also like to provide further assurances on the national NHS England work
taking place around the Reports to Prevent Future Deaths. All reports received are
discussed by the Regulation 28 Working Group, comprising Regional Medical
Directors, and other clinical and quality colleagues from across the regions. This
ensures that key learnings and insights around events, such as the sad death of
Graham, are shared across the NHS at both a national and regional level and helps
us to pay close attention to any emerging trends that may require further review and
action.
Thank you for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
National Medical Director
NHS England
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