Coroner warns Barclay of impact of care home and hospital shortages, report shows

The government has been warned of the impact of resource pressures in care homes and hospitals after a man died in an emergency department he was only taken to due to a lack of adult care beds. 

Peter Taheri, Assistant Coroner for Suffolk, sent a Prevention of Future Deaths (PFD) report to Health Secretary Stephen Barclay and NHS England Chief Executive Amanda Pritchard following the conclusion of the inquest into the death of Will Maunick.

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Maunick died in March 2022 from a severe head injury caused by a fall in the emergency department of West Suffolk Hospital. He was in the emergency department because his wife was having unplanned emergency surgery and he was not safe to be left alone at home due to dementia, requiring round-the-clock care.

His admission to the emergency department was a last resort after efforts to find appropriate care while his wife was in hospital proved unsuccessful. At least eight social care providers were contacted as well as other residential homes, but none could provide emergency care for Maunick. ‘The inquest heard undisputed evidence that this was an instance of a national care shortage,’ Taheri’s report noted. 

However, one-to-one supervision was not possible in the overstretched emergency department. The inquest found that Maunick fell while the nursing assistant who was trying to maintain supervision of him had been diverted to another patient experiencing a medical emergency – which the coroner judged not to be a failure by staff members. An internal critical incident had been declared due to pressures in the department, with 32 patients waiting for a bed and a shortfall of around 60 nurses and nursing assistants across the hospital.

‘I found as a fact that those severe pressures – the high demand levels and the deficiency of staff and scarcity of resource – contributed to the death’ Taheri wrote in the PFD report. ‘Firstly, if it had been possible to care for and supervise Will on a constant basis as he needed, then on the balance of probabilities the fall that led directly to his passing would have been prevented and his life would have been prolonged.

‘Secondly, on the balance of probabilities, the scarcity of resource relative to demand contributed to Will not being transferred to a ward – or other more appropriate environment – sooner.’

Taheri noted that the intense environment of the emergency department probably contributed to Maunick’s inclination to wander, after which he fell.

‘If it had been possible to transfer Will to a more suitable environment sooner, then on the balance of probabilities the fall that led directly to his passing would have been prevented and his life would have been prolonged.

‘I found as a fact that, on the balance of probabilities, the lack of availability of more appropriate care contributed to the death.’

Taheri warned in his PFD report that a national care shortage, including insufficient residential care placements, meant there was a risk that similar deaths could occur in future.

‘The severe pressures on the hospital, including the Emergency Department, were such that they were experiencing scarcity of resource relative to demand and a severe deficiency of staff,’ he said. ‘The evidence was that the scarcity of resource experienced was a challenge on the national level, rather than just a particular local issue. If hospitals, including Emergency Departments, do not receive sufficient resource, then circumstances creating a risk of future deaths, due to an inability to provide the required care and / or prompt transfer to an available ward bed or appropriate alternative place, will occur or continue to exist in the future.’

The recipients of the PFD report are expected to respond by 15th June.

Image: camilo jimenez


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