Margaret Bailey: Prevention of future deaths report
Date of report: 03/09/2025
Ref: 2025-0448
Deceased name: Margaret Bailey
Coroner name: Andrew Bridgman
Coroner Area: Manchester South
Category: Community healthcare and emergency services related deaths
This report is being sent to: Secretary of State for Health and Social Care, Department of Health and Social Care | Chief Executive, Care Quality Commission,
| REGULATION 28 REPORT TO PREVENT DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: Secretary of State for Health and Social Care, Department of Health and Social Care. Chief Executive, Care Quality Commission, | |
| 1 | CORONER I am Andrew Bridgman, Assistant Coroner, for the coroner area of South Manchester |
| 2 | CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 |
| 3 | INVESTIGATION and INQUEST On 31.01.24 an investigation commenced into the death of Margaret Bailey who died on 17.12.23 at her home address. Margaret was aged 73 years, having been born on 12.01.49. Interested Persons Margaret Bailey’s Right at Home Stepping Hill Hospital Stockport MBC The inquest concluded on 18.06.25. The medical cause of death was 1a) Aspiration of Gastric Contents 1b) Episode of vomiting 1c) 1d) 2 Multiple Sclerosis How, when and where Margaret Bailey died at her home on 17 December 2023 having been sick while resting/sleeping in her bed giving rise to an extensive aspiration of the stomach contents. Margaret Bailey was diagnosed with multiple sclerosis in her early 30’s and at the time of her death was bed-bound and wholly dependent for all personal care. Although MB suffered with mild dysphagia she did not have a history of reflux or vomiting, and the cause of her vomiting is not known. Conclusion Narrative: Died as a consequence of a reduced gag reflex and ability to protect the airway; a recognised symptom of multiple sclerosis. |
| 4 | CIRCUMSTANCES OF THE DEATH At the time of her death Margaret Bailey lived at her own home, with a care package provided by Right at Home – a provider of domiciliary care – commissioned by Stockport MBC. Margaret had a 24hr Live-in carer, supported by Pop-in carers (4 x 30 mins per day) and a Cover carer for 2hrs per day. Direct care was averaged at 12hrs per day. On the morning of 17.12.23, when the 1st Pop-in carer attended to assist the Live-in Carer to get Margaret up, it was noted that Margaret had suffered a episode of diarrhoea. Margaret was cleaned and changed. No other concerns were noted. The 2nd Pop-in carer arrived at about 11.20hrs. This carer felt that Margaret looked unwell and contacted Right at Home office to report this, as per policy. The office note states that the carer was advised “we will monitor and get in touch with gp tomorrow if still under the weather”. The Cover-carer attended at about 13.13hrs (2hrs). The Cover-carer had read the notes and was aware of the earlier call to the office re Margaret but had not received any information as to ‘monitoring’ her. This carer noted that Margaret was hot and sweaty, with cold hands and feet. Margaret was sat out in her chair. Margaret’s daughter happened to visit at the same time. There was conflicting evidence as to whether a thermometer was available in the home. The carer said not. The daughter said there was. The carers evidence was that had a thermometer been available she would have taken Margaret’s temperature. In any event no temperature was taken. The Cover carer left at about 15.00hrs. At some time between 16.00hrs and 16.30hrs when the 3rd Pop-in carer arrived Margaret was assisted back into her bed for a rest, being positioned, as per usual, semi- prone. She was still looking unwell. The Live-in carer retired to her room to allow Margaret peace. Some time after 18.00hrs and before 18.35hrs the Live-in carer returned to Margaret’s room to discover that she had been sick and was unresponsive. CPR was commenced. Paramedics attended but Margaret was clearly deceased. Death confirmed at 18.41hrs. Post-mortem examination evidence was that the extent of aspiration was so great that even in a hospital setting it is unlikely that resuscitation would have been successful. |
| 5 | CORONER’S CONCERNS 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. On the ‘office’ receiving a call from a carer reporting, as here, that a client appears to be unwell there is no algorithm for the call handler (who tends to be an assistant manager/manager but with no medical background) to follow to triage the client, setting out why the client appears unwell and to then determine a course of action. The direction of the conversation is simply left to the ‘office’. 2. There was no ability for the carer reporting that Margaret was unwell to carry out any basic observations, neither before the call to the office nor after it, in order that Margaret could be monitored as per the advice given or to at least provide a baseline for monitoring, not even a temperature reading. Most family homes, caring for children or physically vulnerable adults, would have at least a thermometer, and perhaps a pulse oximeter, maybe even a blood pressure machine. |
| 6 | ACTION SHOULD BE TAKEN Those providing domiciliary support to enable people to live in their own homes, with or without involvement of family, should be properly able to assess a client’s health where it is thought that they may be unwell, more especially where that client is wholly dependent on care and can take no measures themselves. It imperative that a carer is given adequate and appropriate advice when they raise concerns about a client’s general health and that cannot be achieved with an ad hoc triage and without basic observations being known such as temperature, pulse rate, and O2 sats, to inform the process. In my opinion unless action is taken to ensure that providers of domiciliary care have a proper triage system in place, an algorithm and the ability for carers to take basic observations when concerns are raised then there is a risk of future deaths and I believe you have the power to take such action. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report 29th October 2025. The 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. |
| 8 | COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely,who may find it useful or of interest. Margaret’s family Right at Home Stepping Hill Hospital Stockport MBC 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 form. 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. |
| 9 | Dated this day 3rd of September 2025 Andrew Bridgman HM Assistant Coroner |