Peter Good

I am Chris Morris, Area Coroner for Manchester South.

On 28 th June 2024, I opened an inquest into the death of Peter Good who died on 9 th January 2024 at Stepping Hill Hospital, Stockport, aged 64 years. The investigation concluded with the inquest which I heard on 17 th December 2024. A post mortem examination undertaken by a consultant forensic pathologist on the Home Office  Register determined Mr Good died as a consequence of: 1) a) Pneumonia; 1) b) Cerebral infarction, Parkinson’s disease and skin ulceration. At the end of the inquest, I recorded a narrative conclusion to the effect that Mr Good died as a  consequence of complications arising from a previous cerebral infarction, Parkinson’s disease and  skin ulceration which had significantly deteriorated whilst at the nursing home from which he was  admitted to hospital for the final time.

Mr Good was a resident at Hilltop Hall Nursing Home who was nursed in bed as a result of complex  care needs particularly arising from a previous cerebral infarction. On 26 th December 2023, Mr Good was admitted to Stepping Hill Hospital, Stockport with a blocked gastrostomy tube. On admission, Mr Good was noted to be in poor condition exhibiting what clinical staff perceived as  signs of prolonged neglect, leading to a safeguarding alert being raised. Despite treatment with antibiotics, Mr Good deteriorated further whilst in hospital and died on 9 th 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 court heard evidence that a safeguarding alert was raised by nursing staff at Stepping Hill  Hospital shortly after admission on the basis that Mr Good appeared to them very dirty and  unkempt with some of his wounds looking and smelling infected. It was further suggested that on  admission, Mr Good was noted to exhibit poor oral hygiene, with calculus-covered teeth which the  hospital safeguarding nurse regarded as indicative of prolonged neglect. Whilst the Nursing Home’s Deputy Manager gave evidence to the effect that she did not recognise  this description of Mr Good, she accepted she had last provided care to him several weeks prior to  his admission to hospital. I am concerned in the light of this description that Harbour Healthcare as the owner and operator of Hilltop Hall has not instigated its own investigation into the way which Mr Good was cared for, with a view to considering any ongoing risk of harm to other residents and whether any learning can be  derived for staff and managers of the home.

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