Winnie Harrop

I am Jyoti Gill, HM Assistant Coroner, for the coroner area of Manchester South

On 2 nd September 2024 an investigation commenced into the death of Winnie Harrop,  age 89. The investigation concluded at the end of the inquest on 4th February 2025. The conclusion of the inquest was one of Narrative: Died as a consequence of previously  undiagnosed vascular dementia the effects of which were exacerbated by over-sedation  in hospital and the contraindicated removal of oxygen prior to discharge. Ms Harrop’s  death was contributed to by neglect.  The medical cause of death was : 1a) Cerebral hypoxia. 1b) Administration of intravenous lorazepam, 2) vascular dementia, cerebrovascular disease, fracture of right maxillary sinus,  fracture of right orbital floor, ischaemic heart disease, congestive cardiac failure.

On 12 August 2024 around 5 pm Ms Harrop collapsed at the Lakes Care Centre.  Ms  Harrop was on blood thinning medication and having banged her head was bleeding and so an ambulance was called.  Ms Harrop was taken to Tameside General Hospital. At the hospital Ms Harrop showed significant agitation and so was given a sedative  intravenously for a CT scan to take place.  The CT scan taken showed a fracture of the  right orbital floor and right maxillary sinus.  On 13 August 2024 at 5:23 am Ms Harrop was discharged back to The Lakes Care Centre. During her recent admission Ms Harrop developed a new oxygen requirement but was discharged to the care home without any  oxygen. Care home staff were concerned that Ms Harrop was very drowsy and  unresponsive and called the ambulance.  Ms Harrop was readmitted to Tameside General Hospital at 11 am on 13 August 2024.  Ms Harrop’s condition deteriorated, and  the decision was made to begin end of life care. Ms Harrop died on 16 August 2024 at  Tameside General Hospital.

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could 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) There is no clear guidance between health and social care as to when and in what circumstances it is appropriate to send a patient back to a care home. Ms Harrop was discharged back to the care home less than 24 hours following  her admission despite being overly sedated.  The care home was not a nursing home. Ms Harrop’s discharge letter failed to refer to the level of sedation  provided or that there was a new oxygen requirement.

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