Derek Crowther

I am Chris Morris, Area Coroner for Greater Manchester (South).

On 1 st May 2025, an inquest was opened into the death of Derek Crowther who died on the  Saffron Unit, The Meadows, Stockport on 16 th December 2024, aged 86 years. The investigation concluded with an inquest which I heard on 7 th – 8 th October 2025. A post mortem examination determined Mr Crowther died as a consequence of: 1)a) Intracranial Haemorrhage b) Cerebral Amyloid Angiopathy At the end of the inquest, I recorded a conclusion of Natural Causes.

Mr Crowther died on 16 th December 2024 on the Saffron Unit, The Meadows, Stockport as a  consequence of complications arising from Cerebral Amyloid Angiopathy. Mr Crowther had  been admitted to the Unit for a period of assessment following a profound deterioration in his  dementia.

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. 1.The Court heard evidence that a registered nurse working on the Unit at the one of Mr  Crowther’s death was not up to date with Intermediate Life Support (‘ILS’) training, despite  this being termed ‘mandatory’. Having heard evidence from the Trust’s Clinical Excellence  Lead for Older Peoples’ Services, I am concerned that instances continue to arise across the Trust whereby clinical staff are undertaking this despite not being up to date with the required level of Life Support training.

1. Whilst the Court heard evidence as to relevant changes made to the Trust’s Observations  Policy since Mr Crowther’s death, I am concerned that despite having an Electronic Patient  Records system, there is currently no mechanism in use on the wards for contemporaneous  digital recording of observations. I am concerned that an ongoing risk of future deaths arises from this position, in the view of the potential for such systems to accurately record timings  of observations, facilitate trend analysis (particularly in the context of a deteriorating  patient), and reduce the potential for errors, either arising from incorrect / unclear manual  recording of observations

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

th December 2025 . 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.