Re Alan Massam (PFD report sent to SSHSC, Greater Manchester Health and Social Care Partnership and CQC) [2021] MHLO 3

Discharge to care home The coroner's concerns included: (1) there was no clear agreement or arrangement between agencies as to how effectively to share information in complex cases such as this; (2) there was no national guidance/protocol about what an acute trust should do if attempts to contact a home are unsuccessful or about the obligation to ensure the home can accept the patient back (the care home had not answered the phone but, owing to his needs, would not have accepted him if asked; no observations were made before discharge and no discharge notice was sent with him); (3) there was no defined escalation process in the care home to ensure that the risk presented by his refusal of medication and fluids was recognised and acted upon; (4) there was a national shortage of suitable beds within the adult care sector for complex cases so, after the care home served notice on the family, he remained in a home where staff felt they could no longer safely meet his care needs during the search for a replacement.

Metadata on Judiciary website

29 April 2021 - Prevention of Future Deaths - Care Home Health related deaths - Community health care and emergency services related deaths - Hospital Death (Clinical Procedures and medical management) related deaths - Mental Health related deaths - PFD Report - Coroner

Date of report: 26 April 2021

Ref: 2021-0120

Deceased name: Alan Massam

Coroner name: Alison Mutch

Coroner Area: Manchester South

Category: Care Home Health related deaths - Hospital Death (Clinical Procedures and medical management) related deaths - Community health care - Mental Health related deaths

This report is being sent to: SoS of Health and Social Care, Greater Manchester Health and Social Care Partnership and Care Quality Commission

External links

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Full judgment: No Bailii link (neutral citation is unknown or not applicable)
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Subject(s):

Date: 26/4/21🔍

Court: Coroner🔍

Judge(s):

Parties:

  • Alan Massam🔍
  • Secretary of State for Health and Social Care🔍
  • Greater Manchester Health and Social Care Partnership🔍
  • Care Quality Commission🔍

Citation number(s):

What links here:

Published: 30/4/21 09:01

Cached: 2024-04-26 13:05:57

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