Greater Manchester Combined Authority
Other
Noted
The response acknowledges concerns about delays in EMI placement due to bed shortages, suggests contacting Stockport Council for clarification, and mentions ongoing work on market shaping and hospital discharge pathways within the Greater Manchester Adult Social Care Transformation Programme. (AI summary)
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Dear Ms Mutch,
Re: Regulation 28 Report to Prevent Future Deaths – Reginald Collins, date of death 22nd October 2019
Thank you for your Regulation 28 Report concerning the death of Mr Collins on 22nd October 2019. Firstly, I would like to express my deep condolences to Mr Collin’s family.
The regulation 28 report concludes Mr Collin’s death was a result of 1a) Aspiration pneumonia on a background of immobility; 1b) Fracture neck of femur following a fall; and II) Ischaemic heart disease, Frailty
Following the inquest you raised concerns in your Regulation 28 Report to NHS England; that
1. The inquest heard that Mr Collins could have been discharged on 19th September when he was medically optimised. However he remained in an acute hospital setting until his death on 22nd October because of the challenges of finding a suitable EMI placement for him.
2. The inquest heard that an EMI placement would have met his needs in a way that an acute hospital setting could not.
3. The inquest was told that the delay was due in large part to a lack of suitable complex EMI beds both locally and nationally .
4. The delay in his discharge via Adult Social Care meant that an acute hospital bed was not available to the Trust.
From the discussion with Stockport Council, the Local Authority Director of Adult Services (DASS) and commissioners, it appears that the Local Authority has not had the opportunity to respond to the coroner on this specific event and thus not had
sight of all the relevant information. The Local Authority did have potential provision and it appears did actually offer this. Can we suggest that contact is made with them for further information and clarification on these points. The DASS is more than happy to liaise accordingly ( @stockport.gov.uk).
As some additional information, as part of the work of the Greater Manchester Adult Social Care Transformation Programme led by the GMHSCP, there is a significant amount of work taking place around market shaping and development and in particular around new and improved models of care and support for people with complex needs. We recognise this is an area which needs improving nationally. We are also working closely across the system on hospital discharge and now have a GM Discharge Pathway and good Discharge to Assess (D2A) system in place.
The huge pressures on Trusts is fully acknowledged and we continue to support and drive the ‘Home First’ approach as evidenced in the majority of work including our Living Well at Home Programme here in GM.
I hope this information is to your satisfaction and please do not hesitate to contact me if you need any further information.
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.
Re: Regulation 28 Report to Prevent Future Deaths – Reginald Collins, date of death 22nd October 2019
Thank you for your Regulation 28 Report concerning the death of Mr Collins on 22nd October 2019. Firstly, I would like to express my deep condolences to Mr Collin’s family.
The regulation 28 report concludes Mr Collin’s death was a result of 1a) Aspiration pneumonia on a background of immobility; 1b) Fracture neck of femur following a fall; and II) Ischaemic heart disease, Frailty
Following the inquest you raised concerns in your Regulation 28 Report to NHS England; that
1. The inquest heard that Mr Collins could have been discharged on 19th September when he was medically optimised. However he remained in an acute hospital setting until his death on 22nd October because of the challenges of finding a suitable EMI placement for him.
2. The inquest heard that an EMI placement would have met his needs in a way that an acute hospital setting could not.
3. The inquest was told that the delay was due in large part to a lack of suitable complex EMI beds both locally and nationally .
4. The delay in his discharge via Adult Social Care meant that an acute hospital bed was not available to the Trust.
From the discussion with Stockport Council, the Local Authority Director of Adult Services (DASS) and commissioners, it appears that the Local Authority has not had the opportunity to respond to the coroner on this specific event and thus not had
sight of all the relevant information. The Local Authority did have potential provision and it appears did actually offer this. Can we suggest that contact is made with them for further information and clarification on these points. The DASS is more than happy to liaise accordingly ( @stockport.gov.uk).
As some additional information, as part of the work of the Greater Manchester Adult Social Care Transformation Programme led by the GMHSCP, there is a significant amount of work taking place around market shaping and development and in particular around new and improved models of care and support for people with complex needs. We recognise this is an area which needs improving nationally. We are also working closely across the system on hospital discharge and now have a GM Discharge Pathway and good Discharge to Assess (D2A) system in place.
The huge pressures on Trusts is fully acknowledged and we continue to support and drive the ‘Home First’ approach as evidenced in the majority of work including our Living Well at Home Programme here in GM.
I hope this information is to your satisfaction and please do not hesitate to contact me if you need any further information.
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.