UK Inquiry Tracker

Victoria Cartwright

PFD Report Historic (No Identified Response) Ref: 2022-0182

Date of Report 17 June 2022

Coroner Rachel Syed

Coroner Area Manchester West

Response Deadline est. 15 November 2022

Alcohol, drug and medication related deaths

Judiciary.uk Report PDF

No published response · Over 2 years old

Sent To

Wigan Discharge Team

Response Status

Responses 0 of 1

56-Day Deadline 15 Nov 2022

Over 2 years old — no identified published response

About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Coroner's Concerns AI summary

There was a significant lack of collaborative working and information sharing between healthcare agencies during discharge, resulting in a patient with complex needs being sent to unsuitable accommodation against clinical recommendations.

Action Should Be Taken

In mv ooinion urgent action should be taken to prevent future deaths and I 8

Report Sections

Investigation and Inquest

On Wednesday 5th January 2022 I commenced an investigation into the death of Victoria Cartwright, 36. The investigation concluded at the end of the inquest on Thursday 16th June 2022. The medical cause of death was: 1 a) Hypothermia
2) Alcohol Intoxication The conclusion of the inquest was 'Accident'.

Circumstances of the Death

The deceased was pronounced dead on the 26th December 2021, in the car park, rear of the Ball and Boot Pub, Orchard Street, Wigan. The deceased had a complicated medical history including a long battle with alcohol abuse, resulting in many hospital admissions, as a consequence of being found in the street intoxicated and unable to take care of herself. The deceased had completed a private detoxification and rehabilitation programme but despite this was unable to abstain from alcohol misuse. She was known her to local alcohol and mental health teams. On the 1oth November 2021 , she was admitted to hospital by the Police following welfare concerns. On the 19th November 2021, a Mental Health Team referral was made and an assessment revealed an impression that the deceased was suffering from alcohol related brain disease and Korsakoff s Syndrome. A Mental Health Clinician recommended a 24 hour care placement be out in olace as the deceased would be unable to manaae indeoendentlv.