A coroner has urged action to be taken after an elderly man died after developing sepsis when his catheter was not changed for weeks.

Barry Preston, 73, who had no family, had been under the care of mental health services for more than 50 years and, since 1993, had lived in supported accommodation in the community.

An inquest into Mr Preston's death heard he suffered complications following a series of falls and sepsis.

Alison Mutch, senior coroner for Greater Manchester South, says changes must be made to prevent deaths such as Mr Preston's from happening in the future.

Bolton Council delegated responsibility for Mr Preston's care to Greater Manchester Mental Health. But on October 28, 2018 the pensioner was taken to the Royal Bolton Hospital after suffering a fractured skull in a fall at home.

The inquest heard that there was no assessment of his capacity and no meeting to discuss his best interests and he was transferred to the Bolton Council-run Laburnum Lodge care home on November 10.

However, he was back in hospital within 24 hours after falling twice more and suffering another bleed on the brain.

Still no meeting was held or overall assessment of his needs and, in addition, his medical notes wrongly stated that he had a long-term catheter in place.

His short-term catheter had been inserted on November 4 and should have been replaced after four weeks.

But the error was not spotted until January 23 when, after being transferred to Trafford General Hospital for rehabilitation, he developed symptoms of urosepsis, a form of sepsis caused by urinary tract infections.

Despite being treated with antibiotics, Mr Preston continued to deteriorate and he developed pneumonia, dying at Trafford General Hospital on February 2 last year.

At the inquest Ms Mutch recorded a narrative conclusion that Mr Preston “died from natural causes contributed to by a catheter that was not replaced within the guidance time period and the recognised complications of a series of falls.”

“In my opinion there is a risk that future deaths will occur unless action is taken,” she says in a letter to the authorities responsible for Mr Preston’s care.

She has sent a Regulation 28 Report to Prevent Future Deaths notice to the bosses of Bolton Council, the Greater Manchester Mental Health NHS Foundation Trusts and the Royal Bolton Hospital.

They have until the end of June to respond, outlining the steps they are taking to prevent future death like Mr Preston’s occurring.

In particular the coroner says she is concerned about the quality of documentation which was part of the reason Mr Preston was thought to be using a long term catheter.

In addition Mr Preston was not placed on wards at the Royal Bolton Hospital which were suitable for his needs and while he was being treated there was “no coordination or ownership of his care”.

The coroner adds that while Mr Preston has a care co-ordinator in the community, they did not take a lead in ensuring he was being supported while in hospital.

Once he was unsupervised while eating and dropped a pudding on himself that was so hot that it burned him.

“There was a lack of understanding between agencies of roles and responsibilities,” stated the coroner.

Staff did not understand that Mr Preston lacked the ability to make decisions about his own care, the coroner said.

“Acquiescence by him was seen as him understanding and having capacity,” wrote Ms Mutch.

The Bolton News requested a comment from Bolton Council, the Royal Bolton Hospital and Greater Manchester Mental Health Trust.

In a joint statement they replied: “It would be inappropriate for us to comment on this further until we have formally responded to the coroner as requested.”