Patrick Griffin
PFD Report
All Responded
Ref: 2026-0114
All 1 response received
· Deadline: 21 Apr 2026
Coroner's Concerns (AI summary)
A patient with advanced dementia became dehydrated and severely constipated at a care facility, despite recognized needs for dietary, fluid, and personal care support.
View full coroner's concerns
Mr Griffin lived with advanced dementia and moved into Moss Cottage on temporary basis on 18 July 2025 to afford his wife and main carer a period of respite. I am concerned that, despite it being recognised that Mr Griffin needed support with dietary and fluid intake, and full assistance with hygiene and personal care, when admitted to hospital on 6 August 2025, he was noted:
1) To be dehydrated; and
2) Not to have opened his bowels for 7 days.
1) To be dehydrated; and
2) Not to have opened his bowels for 7 days.
Responses
Action Taken
• The organisation has thoroughly investigated the concerns and reflected seriously upon the contents of the report, the evidence heard, and the findings made at the inquest. • Investigations and remedial actions commenced earlier following the identification of concerns and actions to be taken, as part of agreed lessons learned outcomes, with the approval of the Tameside Safeguarding Team in August and September 2025. • The following actions have been incorporated and discussed across the wider organisation as part of our approach to continuous quality improvement and lessons learned following a full audit of the service by the senior management team and a thorough investigation. (AI summary)
• The organisation has thoroughly investigated the concerns and reflected seriously upon the contents of the report, the evidence heard, and the findings made at the inquest. • Investigations and remedial actions commenced earlier following the identification of concerns and actions to be taken, as part of agreed lessons learned outcomes, with the approval of the Tameside Safeguarding Team in August and September 2025. • The following actions have been incorporated and discussed across the wider organisation as part of our approach to continuous quality improvement and lessons learned following a full audit of the service by the senior management team and a thorough investigation. (AI summary)
View full response
Dear Mr Morris,
Inquest touching the death of Mr Patrick James Griffin
Thank you for your Regulation 28 report of 24th February 2026, following the inquest into the death of Mr Griffin. This letter sets out the response to your concerns that unless action is taken, there is a risk that future deaths will occur.
I anticipate that a copy of this letter will be shared with Mr Griffin’s family and would like to take this opportunity to express my sincere condolences for their loss.
Coroner’s Matters of Concern
“Mr Griffin lived with advanced dementia and moved into Moss Cottage on a temporary basis on 18 July 2025 to afford his wife and main carer a period of respite. I am concerned that, despite it being recognised that Mr Griffin needed support with dietary and fluid intake, and full assistance with hygiene and personal care, when admitted to hospital on 6 August 2025, he was noted:
1) To be dehydrated; and
2) Not to have opened his bowels for 7 days.”
Response
I confirm that as an organisation we have thoroughly investigated your concerns and reflected seriously upon the contents of your report, the evidence heard, and the findings made at the inquest held before you on the 30 January 2026. I can also confirm that our investigations and remedial actions commenced earlier following the identification of concerns and actions to be taken, as part of agreed lessons learned outcomes, with the approval of the Tameside Safeguarding Team in August and September 2025.
Consequently, we have incorporated the following actions and discussed across the wider organisation as part of our approach to continuous quality improvement and lessons learned following a full audit of the service by the senior management team and a thorough investigation.
Caring Moss Cottage Ltd, Registration No`: 06773947 1st Floor Cloister House, Riverside, New Bailey Street, Manchester, M35FS Moss Cottage Nursing Home, 34 Manchester Road, Ashton-under-Lyne, OL7 0BZ Tel: 0161 343 2557 Actions taken
The leadership team at Moss Cottage were placed on a performance plan and provided with additional training and mentoring to strengthen their skillset and address the issues identified. All Care Staff and Nurses have been allocated and completed the following training:
• Communication, documentation and reporting
• Nutrition
• Malnutrition and dehydration
All Care Staff and Nurses have received the following policies and procedures via a reading list on the quality compliance software programme that is in use:
• Record Keeping
• Duty of Care
• Nutrition and Hydration
• Bladder and Bowel Care
• Care Communication
• Patient Centred Care and Support
• Nurse Accountability and Delegation (Nurses)
• Leadership and Management (Nurses)
The daily handover has been reviewed, and we have added additional sections, which include dietary intake, fluid consumption and elimination, to aide early intervention.
Additionally, a new Management Team is now in place at Moss Cottage, and the Manager is spot checking and auditing that documentation is robust throughout the week and the Senior Governance Manager is auditing monthly. Fluid balance charts and bowel activity have been added to the Managers daily walk round.
Thank you again for bringing these concerns to my attention. I hope that this response offers you assurance that we have made and continue to make improvements to mitigate risk for all residents residing at Moss Cottage.
Sincerely yours,
Managing Director
Inquest touching the death of Mr Patrick James Griffin
Thank you for your Regulation 28 report of 24th February 2026, following the inquest into the death of Mr Griffin. This letter sets out the response to your concerns that unless action is taken, there is a risk that future deaths will occur.
I anticipate that a copy of this letter will be shared with Mr Griffin’s family and would like to take this opportunity to express my sincere condolences for their loss.
Coroner’s Matters of Concern
“Mr Griffin lived with advanced dementia and moved into Moss Cottage on a temporary basis on 18 July 2025 to afford his wife and main carer a period of respite. I am concerned that, despite it being recognised that Mr Griffin needed support with dietary and fluid intake, and full assistance with hygiene and personal care, when admitted to hospital on 6 August 2025, he was noted:
1) To be dehydrated; and
2) Not to have opened his bowels for 7 days.”
Response
I confirm that as an organisation we have thoroughly investigated your concerns and reflected seriously upon the contents of your report, the evidence heard, and the findings made at the inquest held before you on the 30 January 2026. I can also confirm that our investigations and remedial actions commenced earlier following the identification of concerns and actions to be taken, as part of agreed lessons learned outcomes, with the approval of the Tameside Safeguarding Team in August and September 2025.
Consequently, we have incorporated the following actions and discussed across the wider organisation as part of our approach to continuous quality improvement and lessons learned following a full audit of the service by the senior management team and a thorough investigation.
Caring Moss Cottage Ltd, Registration No`: 06773947 1st Floor Cloister House, Riverside, New Bailey Street, Manchester, M35FS Moss Cottage Nursing Home, 34 Manchester Road, Ashton-under-Lyne, OL7 0BZ Tel: 0161 343 2557 Actions taken
The leadership team at Moss Cottage were placed on a performance plan and provided with additional training and mentoring to strengthen their skillset and address the issues identified. All Care Staff and Nurses have been allocated and completed the following training:
• Communication, documentation and reporting
• Nutrition
• Malnutrition and dehydration
All Care Staff and Nurses have received the following policies and procedures via a reading list on the quality compliance software programme that is in use:
• Record Keeping
• Duty of Care
• Nutrition and Hydration
• Bladder and Bowel Care
• Care Communication
• Patient Centred Care and Support
• Nurse Accountability and Delegation (Nurses)
• Leadership and Management (Nurses)
The daily handover has been reviewed, and we have added additional sections, which include dietary intake, fluid consumption and elimination, to aide early intervention.
Additionally, a new Management Team is now in place at Moss Cottage, and the Manager is spot checking and auditing that documentation is robust throughout the week and the Senior Governance Manager is auditing monthly. Fluid balance charts and bowel activity have been added to the Managers daily walk round.
Thank you again for bringing these concerns to my attention. I hope that this response offers you assurance that we have made and continue to make improvements to mitigate risk for all residents residing at Moss Cottage.
Sincerely yours,
Managing Director
Sent To
- Caring UK
Response Status
Linked responses
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56-Day Deadline
21 Apr 2026
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 3 September 2025, an inquest was opened by Alison Mutch OBE, Senior Coroner for Greater Manchester (South) into the death of Patrick Griffin who died at the Stamford Unit, Tameside Hospital on 17 August 2025, aged 82 years. The investigation concluded with an inquest which I heard on 30 January 2026. The inquest heard medical evidence that Mr Griffin died as a consequence of:
1a) Bronchopneumonia
2) Alzheimer’s Disease At the end of the inquest, I recorded a narrative conclusion, finding that Mr Griffin died in hospital from Bronchopneumonia having been admitted from a care home as a result of a number of his basic care needs not being met.
1a) Bronchopneumonia
2) Alzheimer’s Disease At the end of the inquest, I recorded a narrative conclusion, finding that Mr Griffin died in hospital from Bronchopneumonia having been admitted from a care home as a result of a number of his basic care needs not being met.
Circumstances of the Death
Mr Griffin died on 17 August 2025 at the Stamford Unit, Tameside General Hospital, Ashton-under-Lyne as a consequence of Bronchopneumonia against a background of Alzheimer’s Disease. Mr Griffin was admitted to Tameside General Hospital from Moss Cottage where he was receiving residential care on a temporary basis.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.