Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0114, written 24 Feb 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Feb 2026 |
|---|---|
| Reference | 2026-0114 |
| Deceased | Patrick Griffin |
| 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: , Managing Director, Caring UK Ltd 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 3 September 2025, an inquest was opened by Alison Mutch OBE, Senior Coroner for Greater Manchester (South) into the death of Patrick Griffin who died at the Stamford Unit, Tameside Hospital on 17 August 2025, aged 82 years. The investigation concluded with an inquest which I heard on 30 January 2026. The inquest heard medical evidence that Mr Griffin died as a consequence of: 1a) Bronchopneumonia 2) Alzheimer’s Disease At the end of the inquest, I recorded a narrative conclusion, finding that Mr Griffin died in hospital from Bronchopneumonia having been admitted from a care home as a result of a number of his basic care needs not being met. CIRCUMSTANCES OF THE DEATH Mr Griffin died on 17 August 2025 at the Stamford Unit, Tameside General Hospital, Ashton- under-Lyne as a consequence of Bronchopneumonia against a background of Alzheimer’s Disease. Mr Griffin was admitted to Tameside General Hospital from Moss Cottage where he was receiving residential care on a temporary basis. 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 MATTERS OF CONCERN are as follows. – Mr Griffin lived with advanced dementia and moved into Moss Cottage on temporary basis on 18 July 2025 to afford his wife and main carer a period of respite. I am concerned that, despite it being recognised that Mr Griffin needed support with dietary and fluid intake, and full assistance with hygiene and personal care, when admitted to hospital on 6 August 2025, he was noted: 1) To be dehydrated; and 2) Not to have opened his bowels for 7 days. 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 21st April 2026 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 Griffin’s daughter, Tameside Metropolitan Borough Council, and the Care Quality Commission who may find it useful or of interest. 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 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: 24th February 2026 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.
Moss Cottage Nursing Home, 34 Manchester Road, Ashton-under-Lyne, OL7 0BZ Tel: 0161 343 2557 Coroners Court 1 Mount Tabor Street, Stockport SK1 3AG Coroners.office@stockport.gov.uk 27th March 2026 Dear Mr Morris, Inquest touching the death of Mr Patrick James Griffin Thank you for your Regulation 28 report of 24th February 2026, following the inquest into the death of Mr Griffin. This letter sets out the response to your concerns that unless action is taken, there is a risk that future deaths will occur. I anticipate that a copy of this letter will be shared with Mr Griffin’s family and would like to take this opportunity to express my sincere condolences for their loss. Coroner’s Matters of Concern “Mr Griffin lived with advanced dementia and moved into Moss Cottage on a temporary basis on 18 July 2025 to afford his wife and main carer a period of respite. I am concerned that, despite it being recognised that Mr Griffin needed support with dietary and fluid intake, and full assistance with hygiene and personal care, when admitted to hospital on 6 August 2025, he was noted: 1) To be dehydrated; and 2) Not to have opened his bowels for 7 days.” Response I confirm that as an organisation we have thoroughly investigated your concerns and reflected seriously upon the contents of your report, the evidence heard, and the findings made at the inquest held before you on the 30 January 2026. I can also confirm that our investigations and remedial actions commenced earlier following the identification of concerns and actions to be taken, as part of agreed lessons learned outcomes, with the approval of the Tameside Safeguarding Team in August and September 2025. Consequently, we have incorporated the following actions and discussed across the wider organisation as part of our approach to continuous quality improvement and lessons learned following a full audit of the service by the senior management team and a thorough investigation. Caring Moss Cottage Ltd, Registration No`: 06773947 1st Floor Cloister House, Riverside, New Bailey Street, Manchester, M35FS Moss Cottage Nursing Home, 34 Manchester Road, Ashton-under-Lyne, OL7 0BZ Tel: 0161 343 2557 Actions taken The leadership team at Moss Cottage were placed on a performance plan and provided with additional training and mentoring to strengthen their skillset and address the issues identified. All Care Staff and Nurses have been allocated and completed the following training: • Communication, documentation and reporting • Nutrition • Malnutrition and dehydration All Care Staff and Nurses have received the following policies and procedures via a reading list on the quality compliance software programme that is in use: • Record Keeping • Duty of Care • Nutrition and Hydration • Bladder and Bowel Care • Care Communication • Patient Centred Care and Support • Nurse Accountability and Delegation (Nurses) • Leadership and Management (Nurses) The daily handover has been reviewed, and we have added additional sections, which include dietary intake, fluid consumption and elimination, to aide early intervention. Additionally, a new Management Team is now in place at Moss Cottage, and the Manager is spot checking and auditing that documentation is robust throughout the week and the Senior Governance Manager is auditing monthly. Fluid balance charts and bowel activity have been added to the Managers daily walk round. Thank you again for bringing these concerns to my attention. I hope that this response offers you assurance that we have made and continue to make improvements to mitigate risk for all residents residing at Moss Cottage. Sincerely yours, Managing Director Caring Moss Cottage Ltd, Registration No`: 06773947 1st Floor Cloister House, Riverside, New Bailey Street, Manchester, M35FS
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