Victoria Cartwright
PFD Report
Historic (No Identified Response)
Ref: 2022-0182
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.
View full coroner's concerns
Whilst is it accepted that no evidence was heard directly from the hospital about the specific circumstances of both hospital discharges, two witnesses attended the Inquest and during their evidence concerns were raised regarding lack of collaborative working with key external agencies during the discharge processes. The MATIERS OF CONCERN are as follows. Consultant Psychiatrist for Greater Manchester Mental Health Trust stated he had recommended a 24 hour care placement for Victoria to meet her clinical needs. Despite this, she was discharged from hospital to the Mercure Hotel, used to house homeless individuals. stated that this hotel would have been unsuitable for Victoria's medical needs and following her readmission back to hospital, raised similar concerns. He also stated that he was never notified of Victoria's actual discharges. a Recovery Co-Ordinator, employed by We Are With You (formerly Achieve) stated he was never invited to Victoria's MDT meeting and it would have been beneficial for his organisation to have been taken part in this meeting. He concurred that the Mercure Hotel would have been unsuitable accommodation to suit Victoria's complex needs and was not involved in the hospital discharge processes. Evidence highlights a lack of collaborative working between the discharge team, Wigan Hospital, GMMH and Achieve.
Sent To
- Wigan Discharge Team
Response Status
Linked responses
0 of 1
56-Day Deadline
15 Nov 2022
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 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'.
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.
Action Should Be Taken
In mv ooinion urgent action should be taken to prevent future deaths and I 8
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Prevent discharge of hospitalised children with concerns until home is safe
Laming Inquiry
Care and discharge planning
Require consultant or paediatrician permission for discharging children with protection concerns.
Laming Inquiry
Care and discharge planning
Require documented future care plan for discharging children with protection concerns.
Laming Inquiry
Care and discharge planning
Ensure identified GP for children with deliberate harm concerns discharged from hospital.
Laming Inquiry
Care and discharge planning
Establish comprehensive counselling and support services as integral to patient care
Bristol Heart Inquiry
Care and discharge planning
Require every trust to provide a professional bereavement service and online information
Bristol Heart Inquiry
Care and discharge planning
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.