On 25th October 2018, Christopher Murray, Assistant Coroner, opened an inquest into the death of Joseph Kevin Lafferty who died on 24th June 2018at Wythenshawe Hospital, Manchester, at the age of 85 years The investigation concluded with an inquest which heard between 1" _ 4th July 2019 and which concluded with a Narrative conclusion to the effect that Mr Lafferty died as a consequence of a fall at his care home which occurred after he left the building and gained access to an area of grounds to which it was not intended he should have access, whilst unsupervised.

Mr Lafferty was formally diagnosed with dementia in 2014. Over subsequent vears, problems with his short term memory increased and his mobility declined. In January 2018, Mr Lafferty was admitted to hospital following a fall, and treated for an infection It was appreciated that Mr Lafferty' $ condition was nOw such that he could not safely return home Following assessments undertaken in hospital, it was identified Mr Lafferty required 24 hour EMI residential care. As such, on 1" May 2018, Mr Lafferty moved into The Cedars Rest Home, Bowden, Altrincham: Whilst at The Cedars, Mr Lafferty was noted to be wandersome. At around teatime on 11th June 2018,staff at the home realised Mr Lafferty was missing: A search ensued, and he was found outside of the care home in an area it was not intended he should have access to with serious injuries: An ambulance was called at 17:41 and arrived on scene approximately two hours later: Mr Lafferty was taken to Wythenshawe Hospital where he subsequently died. A post mortem examination concluded Mr Lafferty died a5 a consequence of:
1) A) Bronchopneumonia with congestive cardiac failure; due to
1) B) Thoracic trauma on the background of ischaemic heart disease and dementia. the

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