Mark Fernandez

I am Joanne Kearsley, Senior Coroner for the Coroner area of Manchester North

I opened an investigation into the death of Mark Anthony Fernandez on the 30 th October 2024 and the final Inquest hearing took place on the 17 th February 2025 before HM Joanne Kearsley. A conclusion of natural causes was returned.

Mr Fernandez was born with cerebral palsy and complex medical needs. He had been in the care of Oldham Social Services since he was a child.  He was not able to speak and registered blind. Since 2008 he had been residing at a supported living home with full time carers. His care package was provided by Comfort Call. His carers had a wealth of knowledge and understanding as to how Mark communicated, what he liked and disliked, his feeding regime and all aspects of his care and health needs.  They also facilitated weekly visits with a close family member who received similar care. During the day on the 1 st February Mr Fernandez had attended the specialist sarcoma service at Manchester Foundation Trust (“MFT”) following a referral from Rochdale Infirmary. Limited information had been provided as to his level of disability and as such the court heard that a very limited examination was conducted whilst he remained clothed and in his chair.   If MFT had been aware they indicated they would have had the opportunity to obtain a hoist and would have requested bloods before attendance.  They indicated they had now changed their practices. On the 1 st February 2025 Mr Fernandez was admitted to Royal Oldham hospital at 8pm in the evening with suspected meningitis (a rash had become evident).  His carers forwarded his hospital passport and also sent further copies to the hospital following his admission to a ward. Investigations highlighted he had recurring infections and despite treatment, including the insertion of a PEG, he remained in hospital until his death on the 18 th April 2024.  On the 12 th April 2024 following a best interests meeting he was placed on end of life care. The carers and social services involvement in Mark’s life was overlooked and their views and knowledge of Mark was not taken into account in the best interest decision-making process. The court heard that in 2020 the carers had successfully presented evidence against the introduction of a DNAR, at a best interests meeting.

During the course of the inquest the evidence revealed matters giving rise to concern.  In my opinion there is a risk that future deaths will occur unless action is taken.  In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows:- Greater Manchester Integrated Care Board and Northern Care Alliance

1. The referral to the specialist service did not provide adequate information as to his level of care needs to help assist the service conduct an appropriate examination.

Northern Care Alliance, Oldham Social Services, Oldham Independent Mental Capacity Advocate

1. The hospital passport was not utilised.
2. A best interest decision was made without taking into account the views of the long-term carers and social services and their knowledge of him as an individual.

In my opinion action should be taken to prevent future deaths and I believe each of you respectively have the power to take such action.