John Howlett

I am Alison Mutch, Senior Coroner, for the coroner area of South Manchester

On 6 th February 2024 I commenced an investigation into the death of John  Francis HOWLETT. The investigation concluded on the 13 th August 2024 and the  conclusion was one of Narrative: Died from exacerbation of chronic obstructive pulmonary disease contributed to by frailty due to dehydration and poor  nutritional status. The medical cause of death was 1a) Infective exacerbation  of chronic obstructive pulmonary disease II) Frailty

John Francis Howlett had severe chronic obstructive pulmonary disease. He was placed at The Lakes Care Home due to his severe chronic obstructive pulmonary disease. He required oxygen and was bedbound. He became increasingly frail whilst at The Lakes with poor nutrition and fluid intake. He developed an  infection and was admitted to Tameside General Hospital. He was treated but  despite the treatment he continued to decline as a consequence of the  exacerbation of his underlying chronic obstructive pulmonary disease and  frailty. He died at Tameside General Hospital on 31st January 2024.

During the course of the inquest the evidence revealed matters giving rise to  concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. –

1. The inquest heard that on arrival at A and E at Tameside Hospital Mr Howlett spent 22 hours in a corridor despite suffering from an infection  and the distress that this caused. The inquest was told that this was due to the demands on the department and the challenges of moving  patients onto wards due to capacity issues. The inquest was told that  this was not unique to that particular day or indeed to the hospital and  was the picture across the country at that time.
2. The evidence before the inquest indicated that the care home in  question had been of concern in relation to the care offered to residents for some time. It was indicated that action plans were in place  particularly in relation to safeguarding concerns given the vulnerability of residents. However despite those steps being in place and the  concerns the systems were not in place at the care home to robustly  monitor his nutritional status and fluid intake. He became increasingly  frail with decreased physiological reserves as a consequence.

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.