David Bendell
PFD Report
All Responded
Ref: 2025-0292
All 1 response received
· Deadline: 31 Jul 2025
Coroner's Concerns (AI summary)
A lack of step-down community rehabilitation facilities for patients not eligible for inpatient care but too frail for home-only support risks unsafe hospital discharges.
View full coroner's concerns
1. At inquest it was heard in evidence David was discharged from hospital once he was able to transfer from a hospital bed to a commode, and back to the bed. It was acknowledged that David could not walk unaided.
2. David was discharged on the 8th July 2024 under the Stroke Early Supported Discharge Team, that was to provide physiotherapy support in his home on a daily basis. David also had carers to attend four times a day (this being the maximum support available).
3. David’s family described how the ambulance team that brought David home considered taking him straight back to hospital as they did not think he would be able to manage at his home. In addition, one of the first physiotherapists to see David reportedly said ‘this is not going to work’ to family members on seeing David in his accommodation.
4. In evidence it was heard that David’s condition was such that he was not a candidate for hospital-based rehabilitation on a specialist stroke rehabilitation ward. This meant that the only available treatment option for David was to treat him at home.
5. The court was told that there is no step-down community rehabilitation facility to act as a ‘half way house’ for patients like David, if like David they are not eligible for inpatient rehabilitation, but are in reality not physically capable of keeping themselves safe when alone at home.
6. I am therefore concerned that with the current rehabilitation options available being either in a specialist hospital ward or at home, other individuals in David’s situation who are not deemed suitable for in-patient hospital, will also be placed at risk by being sent home when it is not safe to do so.
2. David was discharged on the 8th July 2024 under the Stroke Early Supported Discharge Team, that was to provide physiotherapy support in his home on a daily basis. David also had carers to attend four times a day (this being the maximum support available).
3. David’s family described how the ambulance team that brought David home considered taking him straight back to hospital as they did not think he would be able to manage at his home. In addition, one of the first physiotherapists to see David reportedly said ‘this is not going to work’ to family members on seeing David in his accommodation.
4. In evidence it was heard that David’s condition was such that he was not a candidate for hospital-based rehabilitation on a specialist stroke rehabilitation ward. This meant that the only available treatment option for David was to treat him at home.
5. The court was told that there is no step-down community rehabilitation facility to act as a ‘half way house’ for patients like David, if like David they are not eligible for inpatient rehabilitation, but are in reality not physically capable of keeping themselves safe when alone at home.
6. I am therefore concerned that with the current rehabilitation options available being either in a specialist hospital ward or at home, other individuals in David’s situation who are not deemed suitable for in-patient hospital, will also be placed at risk by being sent home when it is not safe to do so.
Responses
Action Planned
SNEE ICS will work to reinforce the importance of MDT reassessments of patient needs with their multidisciplinary teams. The SNEE ICS Neuro Rehabilitation Programme Group will develop and review a strategic action plan to guide future commissioning of rehabilitation pathways within SNEE. (AI summary)
SNEE ICS will work to reinforce the importance of MDT reassessments of patient needs with their multidisciplinary teams. The SNEE ICS Neuro Rehabilitation Programme Group will develop and review a strategic action plan to guide future commissioning of rehabilitation pathways within SNEE. (AI summary)
View full response
Dear Mr Parsley,
Thank you for the Regulation 28 report of 5 June 2025 sent to the Secretary of State / the Department of Health and Social Care about the death of David Thomas Bendell. I am replying as the Minister with responsibility for Public Health and Prevention.
Firstly, I would like to say how saddened I was to read of the circumstances of David Bendell’s death and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. Thank you for the additional time provided to the department to provide a response to the concerns raised in the report.
The report raises concerns that with current rehabilitation options available being either in a specialist hospital ward or at home, other individuals in David’s situation who are not deemed suitable for in-patient hospital will also be placed at risk by being sent home when it is not safe to do so.
In preparing this response, my officials have made enquiries with NHS England (East of England) to ensure we adequately address your concerns.
Commissioning of stroke services, including rehabilitation, is the responsibility of Integrated Care Boards (ICB).
The integrated community stroke service model (ICSS) came into policy in 2021. This model describes stroke services that are integrated, specialist, responsive and of sufficient intensity to meet the needs of the patient. It also describes delivery of equitable access to the integrated community stroke rehabilitation services regardless of discharge destination.
With regards to step down care to support more dependent patients to rehabilitate, there are three discharge pathways described in the model: (1) to home with no social care required, (2) home with social care support and (3) discharge to a care home (which may be considered as a step-down bed), all with access to needs-led rehabilitation. For those patients discharged to community beds or nursing home care, this constitutes in-reach from integrated community stroke rehabilitation teams, to ensure that the rehabilitation needs of the patients are met.
Suffolk and North East Essex Integrated Care System (SNEE ICS) offers commissioned rehabilitation beds for patients requiring complex post-stroke care with a nationally set criteria. Following clinical assessment by SNEE ICS, Mr Bendell was deemed appropriate for discharge home, supported by Early Supported Discharge (ESD) services and four times a day (QDS) social care package (four visits from a caregiver or healthcare professional) to ensure his care needs were met.
SNEE have stated that, in the context of evolving patient pathways and changing clinical scenarios, it is essential to reinforce with their multidisciplinary team (MDT) colleagues the importance of reassessing a patient’s clinical needs and personal preferences. This ensures that individual patients remain empowered to make informed choices about their ongoing care and health requirements. Learning about patient needs will be shared openly and transparently at the future SNEE System Quality Group meeting in 2025, where senior provider leaders will be present to support shared reflection and continued improvement in practice.
Rehabilitation support can be delivered by SNEE ICS, if appropriate for the individual, within a residential or nursing care home setting. In these circumstances ESD services offer in-reach rehabilitation (either within a community setting or a patients home), functioning as a ‘halfway house’ model.
Rehabilitation bed commissioning is regularly reviewed by the SNEE ICS Neuro Rehabilitation Programme Group, chaired by a Consultant Neurologist. The group meet on a bi-monthly basis. Within the group’s remit is assessing the suitability and capacity of commissioned beds for patients needing specialist neuro-rehabilitation. The group will develop and review a strategic action plan to guide future commissioning of rehabilitation pathways within SNEE.
In addition to work at ICS level by SNEE, NHS England (East of England) has commissioned , University of Essex, to lead a project to map the current community rehabilitation services and their interface with bed-based care within the region. This project is scheduled for completion by October 2025 and will inform future rehabilitation pathway development. The project has committed to share its findings and establish a review process to ensure this information remains current.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
Thank you for the Regulation 28 report of 5 June 2025 sent to the Secretary of State / the Department of Health and Social Care about the death of David Thomas Bendell. I am replying as the Minister with responsibility for Public Health and Prevention.
Firstly, I would like to say how saddened I was to read of the circumstances of David Bendell’s death and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. Thank you for the additional time provided to the department to provide a response to the concerns raised in the report.
The report raises concerns that with current rehabilitation options available being either in a specialist hospital ward or at home, other individuals in David’s situation who are not deemed suitable for in-patient hospital will also be placed at risk by being sent home when it is not safe to do so.
In preparing this response, my officials have made enquiries with NHS England (East of England) to ensure we adequately address your concerns.
Commissioning of stroke services, including rehabilitation, is the responsibility of Integrated Care Boards (ICB).
The integrated community stroke service model (ICSS) came into policy in 2021. This model describes stroke services that are integrated, specialist, responsive and of sufficient intensity to meet the needs of the patient. It also describes delivery of equitable access to the integrated community stroke rehabilitation services regardless of discharge destination.
With regards to step down care to support more dependent patients to rehabilitate, there are three discharge pathways described in the model: (1) to home with no social care required, (2) home with social care support and (3) discharge to a care home (which may be considered as a step-down bed), all with access to needs-led rehabilitation. For those patients discharged to community beds or nursing home care, this constitutes in-reach from integrated community stroke rehabilitation teams, to ensure that the rehabilitation needs of the patients are met.
Suffolk and North East Essex Integrated Care System (SNEE ICS) offers commissioned rehabilitation beds for patients requiring complex post-stroke care with a nationally set criteria. Following clinical assessment by SNEE ICS, Mr Bendell was deemed appropriate for discharge home, supported by Early Supported Discharge (ESD) services and four times a day (QDS) social care package (four visits from a caregiver or healthcare professional) to ensure his care needs were met.
SNEE have stated that, in the context of evolving patient pathways and changing clinical scenarios, it is essential to reinforce with their multidisciplinary team (MDT) colleagues the importance of reassessing a patient’s clinical needs and personal preferences. This ensures that individual patients remain empowered to make informed choices about their ongoing care and health requirements. Learning about patient needs will be shared openly and transparently at the future SNEE System Quality Group meeting in 2025, where senior provider leaders will be present to support shared reflection and continued improvement in practice.
Rehabilitation support can be delivered by SNEE ICS, if appropriate for the individual, within a residential or nursing care home setting. In these circumstances ESD services offer in-reach rehabilitation (either within a community setting or a patients home), functioning as a ‘halfway house’ model.
Rehabilitation bed commissioning is regularly reviewed by the SNEE ICS Neuro Rehabilitation Programme Group, chaired by a Consultant Neurologist. The group meet on a bi-monthly basis. Within the group’s remit is assessing the suitability and capacity of commissioned beds for patients needing specialist neuro-rehabilitation. The group will develop and review a strategic action plan to guide future commissioning of rehabilitation pathways within SNEE.
In addition to work at ICS level by SNEE, NHS England (East of England) has commissioned , University of Essex, to lead a project to map the current community rehabilitation services and their interface with bed-based care within the region. This project is scheduled for completion by October 2025 and will inform future rehabilitation pathway development. The project has committed to share its findings and establish a review process to ensure this information remains current.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
Sent To
- Department of Health and Social Care
Response Status
Linked responses
1 of 1
56-Day Deadline
31 Jul 2025
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 19 July 2024 I commenced an investigation into the death of David Thomas BENDELL aged 79. The investigation concluded at the end of the inquest on 03 June 2025. The conclusion of the inquest was: Narrative Conclusion - Accidental death, contributed to by underlying ill health. The medical cause of death was confirmed as: 1a Large Right Traumatic Subdural Haematoma 1b 1c 1d 2 Chronic Myelomonocytic Leukaemia, Thrombocytopenia, Stroke, Frailty
Circumstances of the Death
David Bendell’s death was recognised at 02:49 on 13th July 2024, at The West Suffolk Hospital, Bury St Edmunds in Suffolk. On the evening of the 12th July 2024 David had been found by his carers (who attended four times daily), injured and slumped on the sofa, so the emergency services were summonsed. David told his carers he had fallen whilst trying to use the commode and shortly after saying this, David became unresponsive and began having seizures. A CT scan undertaken on David after his arrival at the West Suffolk Hospital identified that he had a large bleed to his brain, which was not survivable. David suffered from a blood cancer (leukaemia) which made his blood less able to clot (thrombocytopenia), which would have increased the severity of the bleed to his brain. David had been discharged from hospital on the 8th July 2024 following a recent stroke, and although deemed able to transfer (move from his bed to a commode and return) he was unable to walk. At the time David fell in his home accommodation (warden-controlled housing) no rehabilitation support staff, or carers were present or immediately available to assist him.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.