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InquestIQ

Reginald Collins

1 October 2020Coroner: Alison MutchArea: Manchester South
Clinical decision-making and protocol compliance in acute care assessment and escalationSystemic investigation and learning failures in healthcare governance

Report Content

Coroner

October because of the challenges of finding a suitable EMI placement for him.

  1. The inquest heard that an EMI placement would have met his

needs in a way that an acute hospital setting could not.

  1. The inquest was told that the delay was due in large part to a

lack of suitable complex EMI beds both locally and nationally.

  1. The delay in his discharge via Adult Social Care meant that an

acute hospital bed was not available to the Trust. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 24th September 2020. 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons, namely Mrs wife of the deceased, who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He 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.

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