Source · Prevention of Future Deaths

Doreen Swann

Ref: 2025-0359 Date: 10 Jul 2025 Coroner: Alison Mutch Area: Manchester South Responses identified: 2 / 2 View PDF

Persistent delayed hospital discharges due to social care bed shortages force high-falls-risk patients to remain in acute settings, straining resources and potentially compromising patient safety and bed availability.

Date 10 Jul 2025

56-day deadline 4 Sep 2025

Responses identified 2 of 2

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

View full coroner's concerns

1. The inquest heard evidence that Doreen Swann was only in hospital at the point of her fall because her discharge had been delayed due to a shortage of a suitable social care placement. The evidence was that nursing/caring for high falls risk patients in an acute setting is challenging and resource intensive.
2. The evidence given to the inquest was that this delayed discharge and the ongoing risk it presents was not an isolated incident at TGH -as an example the evidence given was that there were regularly 30 plus patients with a delayed discharge over 3 weeks due to a lack of social care beds .The evidence indicated that this challenge was not unique to Tameside.
3. The evidence indicated that managing a falls risk and the consequential risk to life is better managed outside an acute setting once the clinical need for a hospital stay has passed.
4. Delayed discharges such as Doreen Swann’s reduces the availability of beds for other patients and creates a knock-on impact across the hospital particularly in relation to the Emergency Department.

Responses

2 respondents

Department of Health and Social Care Central Government

4 Sep 2025 PDF

Noted

The Department acknowledges the concerns regarding delayed hospital discharges due to limited social care capacity and describes existing initiatives like the Better Care Fund and care transfer hubs, without committing to new actions. (AI summary)

View full response

Dear Ms Mutch,

Thank you for the Regulation 28 report of 10th July 2025 sent to the Department of Health and Social Care about the death of Doreen Swann. I am replying as the Minister with responsibility for Hospital Discharge and Social Care.

First, I would like to say how saddened I was to read of the circumstances of Doreen Swann’s death, and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention.

This report highlights concerns regarding the impact of limited social care capacity on delays in hospital discharge, and the detrimental effects this can have on individual patient outcomes and broader hospital performance. Importantly, the report identifies that this issue is not unique to Tameside General Hospital. I note this report has also been shared with the hospital and I welcome their engagement with the findings.

As you rightly point out, delayed hospital discharges reduce the number of available hospital beds, causing longer waits in emergency departments and cancellations of planned treatments or surgeries. This puts pressure on the whole system, making it harder to provide timely and effective care. This Government is committed to addressing delayed discharges to ensure hospitals can operate safely and efficiently and people do not spend longer than necessary in hospital beds. As set out in the Hospital discharge and community support guidance, when a patient needs support from social care services to aid discharge, NHS Trusts should inform the relevant local authority of this need as early as possible in the patient’s hospital stay, to allow local areas to co-operate on the person’s discharge planning. To facilitate this collaborative approach, care transfer hubs are available to all acute trusts. These hubs bring together health service, social care, the voluntary sector, and housing to coordinate complex discharges. Their aim is to ensure that patients receive the most appropriate care in the right setting, at the right time. By enabling timely and appropriate discharge, they help reduce the risks associated with prolonged hospital stays, such as loss A1

of independence and increased falls risk, while promoting recovery and patient safety. We are strengthening partnerships between health and social care, as part of the wider shift toward prevention, community-based and digitally enabled care, in line with the 10 Year Health Plan. The Better Care Fund (BCF) is a key part of our plan to address these delays, particularly when they are caused by a shortage of suitable social care, by supporting Integrated Care Boards and local authorities to deliver joined-up health and social care. This year, the BCF will provide £9 billion to help ensure patients receive the right care in the right place, with shared accountability for discharge planning. Additionally, the Spending Review includes over £4 billion additional funding for adult social care by 2028-29, compared to 2025-26, helping local authorities improve services and meet their duties under the Care Act 2014. Thank you again for bringing these concerns to my attention. I hope this provides reassurance that we are taking meaningful action to improve discharge processes and strengthen adult social care provision across the country.

Greater Manchester Integrated Care Integrated Care Board

5 Sep 2025 PDF

Action Planned

NHS GM will create a GM Falls Prevention Strategy with recommendations for each locality. They will identify the number of GM residents at risk of falls and estimate the cost of falls to health and care services. (AI summary)

View full response

Dear Ms. Mutch

Re: Regulation 28 Report to Prevent Future Deaths – Doreen Swann

Thank you for your Regulation 28 Report dated 10 July 2025 regarding the sad death of Doreen Swann. On behalf of NHS Greater Manchester Integrated Care (NHS GM), We would like to begin by offering our sincere condolences to Doreen’s family for their loss.

Thank you for highlighting your concerns during the inquest which concluded on the 5 June 2025. On behalf of NHS GM, we apologise that you have had to bring these matters of concern to our attention. We recognise it is very important to ensure we make the necessary improvements to the quality and safety of future services.

During the inquest you identified the following cause for concern: -

1. The inquest heard evidence that Doreen Swann was only in hospital at the point of her fall because her discharge had been delayed due to a shortage of a suitable social care placement. The evidence was that nursing/caring for high falls risk patients in an acute setting is challenging and resource intensive.
2. The evidence given to the inquest was that this delayed discharge and the ongoing risk it presents was not an isolated incident at TGH -as an example the evidence given was that there were regularly 30 plus patients with a delayed discharge over 3 weeks due to a lack of social care beds .The evidence indicated that this challenge was not unique to Tameside.
3. The evidence indicated that managing a falls risk and the consequential risk to life is better managed outside an acute setting once the clinical need for a hospital stay has passed. Private & Confidential Alison Mutch Senior Coroner for the area of Manchester South Manchester City Coroner’s Office & Court Exchange Floor The Royal Exchange Building Cross Street Manchester M2 7EF

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4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk
4. Delayed discharges such as Doreen Swann’s reduces the availability of beds for other patients and creates a knock-on impact across the hospital particularly in relation to the Emergency Department.

As this report relates to care delivered by Tameside and Glossop Integrated Care NHS Foundation Trust, I have provided a response focusing on action within Tameside locality.

As part of a system led improvement programme, there is a continued focus on patient flow and discharge in Tameside covered by the Trust Deputy Chief Operating Officer, Trust Deputy Chief Nurse, and Director of Adult Services for the Local Authority. Progress against the delivery targets within this improvement programme is monitored through a monthly programme group which was established in April 24 and has delivered a significant reduction in patients with a No Criteria to Reside (NCTR) status over recent months. This means that patients who are medically fit for discharge are being discharged to the right place much quicker. This includes process- mapping to support front-door processes to enable deflection to other services. Intermediate Tier Services (ITS) continues to operate the Acute Frailty Unit to avoid admissions for those patients living with frailty and work streams ongoing for “front door” initiatives in line with the GM 4 Pillars of U&EC improvement.

In terms of oversight of discharge planning and patients with NCTR, the Trust’s Chief Operating Officer chairs a weekly meeting to review Length of Stay and Delayed Transfers of Care. Membership includes local stakeholders and the Director of Adult Services to review each patient and ensure appropriateness of care within a hospital setting and aim to support discharge.

An additional ward was funded and opened in November 2024 which is now fully operational. The ward includes a discharge lounge that supports an increase in patient flow, in its simplest form, patients who are ready for discharge but need to wait for transport, take home medications or relatives to collect them can safety wait in this area. There is also a review of the cohort of patients within the Stamford Unit to ensure appropriate criteria is met.

To respond to the needs of patients within a hospital bed with a high risk of falls, including those with NCTR, a falls deep dive has taken place and a number of areas of improvement identified to include enhanced observations. A falls improvement group is established to review cases and identify learning and improvement actions.

The Director of Adult Services in Tameside holds regular meetings to review the Market Position Statement 2023-26 which provides an overview of the provision of Adult Social Care and support in the borough of Tameside. This sets out the commitment to meet its Care Act duties for the locality in facilitating a vibrant, diverse and sustainable market for Adult Services directive for delivering high quality care and support in the area for the benefit of the local population.

NHS GM recognises the importance of delivery of high-quality care in the best setting and, to enable this, the efficient and effective discharge from secondary care to community-based placement and services. NHS GM has commenced work to demonstrate the benefits in utilising risk stratification to target people at risk of falling to prevent them falling in the next 12 months. We anticipate that this will result in a GM Falls Prevention Strategy with a clear set of recommendations that each locality can tailor to their local population to prevent people from falling. As part of this work, we will identify how many GM residents (65+ years) are at risk of a fall and estimate the cost of a fall to health and care services. This will be shown for those living in the community and those in a care home, for each locality and collectively across GM. A4

4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk We will evidence how these falls can be prevented through targeted support and as a consequence evidence the potential cost savings through this approach to prevent people falling. This will include learning from
• A deep dive in Salford of their current falls prevention support (e.g. strength and balance classes) to help improve uptake, access and value for money.
• Direct application e-falls risk tool in practice in the Wigan SWAN pilot to identify residents at risk of a fall and discuss with them individually how best to prevent them falling.
• Success of utilisation of KoKu (an award-winning platform providing self-managed health care for older adults and NHS approved preventative treatment), Safe Steps (Safe Steps is a digital falls risk assessment tool, designed to reduce the number of falls in health & social care organisations) and other digital technologies.
• The success of return of investment on home adaptations.

I hope that my response has addressed your concerns. Please contact me if you have any further questions or require further information.

Best wishes

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Report sections

Investigation and inquest

On16th January 2025 I commenced an investigation into the death of Doreen Swann. The investigation concluded on the 5th June 2025 and the conclusion was one of Narrative: Died from the complications of a fall when not being cared for in compliance with her risk assessment. The medical cause of death was 1a) Traumatic brain injury 1b) Fall II) Advanced dementia, frailty, E. coli septicaemia, bronchopneumonia.

Circumstances of the death

Doreen Swann was a patient at Tameside General Hospital who had been medically optimised and was awaiting discharged when she developed a further infection. She was a high falls risk. She fell whilst unobserved and when the bed rails were up when they should not have been. She suffered a traumatic brain injury and died at Tameside General Hospital on 13th January 2025.

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2025-0359
Date of report: 10 July 2025
Coroner: Alison Mutch
Coroner area: Manchester South

Responses identified

Responses identified 2 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 4 Sep 2025.

Sent to

Greater Manchester Integrated Care

Department of Health and Social Care

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.