Carole Mather: Prevention of future deaths report

Other related deaths

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Date of report: 08/04/2024

Ref: 2024-0190

Deceased name: Carole Mather

Coroner name: Catherine McKenna

Coroner Area: Manchester North

Category: Other related deaths

This report is being sent to: Department of Health and Social Care

Rt Honourable Victoria Atkins Secretary of State for Health and Social Care
I am Catherine McKenna, Area Coroner for the Coroner area of Manchester North
I make this report under paragraph 7, Schedule 5, of the Coroner’s and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013
On 13 January 2023 an investigation into the death of Carole Mather was commenced. The investigation concluded at the end of the inquest on 5 April 2024. I recorded a conclusion of Misadventure.
The Deceased was 66 years old when her body was found in an alleyway next to her home address on 2 January 2023. A post-mortem examination established that she had died of hypothermia. The Deceased had a background of poor mental health and alcohol dependency. In December 2022, she experienced a downturn in mood and relapsed in her use of alcohol following an extended period of abstinence. She presented at Fairfield General Hospital on 1 January 2023 in an intoxicated state and complaining of shortness of breath. She discharged herself from hospital later that afternoon against medical advice which included the fact that she was placing herself at risk of death by declining hospital admission. The doctor who assessed her as having capacity to make the decision to discharge herself was not aware of her history of involvement with mental health services and did not consult with a senior colleague or obtain advice from on- call psychiatry as was required by the hospital protocol. The Deceased returned home directly from the hospital and was observed by neighbours to be in an intoxicated state on her arrival. Her body was found in an alleyway the following morning.
During the course of the inquest the evidence revealed a matter 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 MATTER OF CONCERN is as follows:
The Court heard that the assessment of mental capacity in those with a chronic dependence on alcohol is often complex and challenging. This is particularly so when it involves a question around the individual’s ability to put their decision into effect (the concept of executive capacity). The decisions can often involve behaviours which give rise to a risk of the individual’s death. It was against this background that the Court heard of the lack of overarching guidance for health and social care practitioners which specifically addresses the application of legal frameworks available to manage and protect those with a chronic dependence on alcohol. Such guidance would be of benefit to health and social care practitioners and by extension to the individuals affected.
In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.
You are under a duty to respond to this report within 56 days of the date of this report, namely 31 May 2024. I, the Area Coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:- Family of the Deceased
Northern Care Alliance NHS Foundation Trust Bury Safeguarding Partnership
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary from. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me the coroner at the time of your response, about the release or the publication of your response by the Chief Coroner.
98 April 2024