McLean, Inquest Touching Upon the Death Of [2025] NICoroner 6 (01 July 2025)

McLean, Inquest Touching Upon the Death Of [2025] NICoroner 6 (01 July 2025)

The deceased's death resulted from a combination of inadequate care, lack of supervision, failure to update care plans, and inappropriate discharge from hospital to a residential setting that could not meet his assessed nursing needs. There were missed opportunities to provide one-to-one care and to move the deceased to a safer environment, and the processes for authorising enhanced care were unduly delayed, prioritising resources over safety.

Citation
[2025] NICoroner 6
Parties
Deceased: William Victor McLean (deceased); Family Member: Alan McLean; Care Provider: Rose Court Care Home; Care Authority: Northern Health and Social Care Trust
Jurisdiction
Northern Ireland
Judgment Date
01 July 2025
Procedural Posture
Inquest / Findings and Conclusion
Outcome
Findings of missed opportunities and failings in care and treatment leading to death; recommendations for improved protocols and procedures.
Legal Topics
Inquest Into Death, Care Home Standards, Duty of Care, Hospital Discharge, Deprivation of Liberty, Falls in Care Settings, Nursing Assessment, Governance in Care Homes
Coronial Law Health Law Elder Law Inquest Into Death Care Home Standards Duty of Care Hospital Discharge Deprivation of Liberty +3 more

Case Brief

Summary, issues, holding and outcome

More case intelligence is available

Unlock the full research layer for this judgment.

Full judgment text Downloadable case file Legal principles 3 Authorities cited 2 Party arguments 2 Amounts and remedies 2
Sign in to unlock

Parties

William Victor McLean (deceased)

Deceased

Alan McLean

Family Member

Rose Court Care Home

Care Provider

Northern Health and Social Care Trust

Care Authority

Procedural Posture

Inquest / Findings and Conclusion

Legal Issues

  1. 1 Whether the care provided to William Victor McLean at Rose Court Care Home and by the Northern Health and Social Care Trust was adequate and appropriate.
  2. 2 Whether there were missed opportunities or failings in the care and treatment leading to his death.
  3. 3 Whether the discharge from hospital to residential care was appropriate given his assessed needs.

Ratio Decidendi

The deceased's death resulted from a combination of inadequate care, lack of supervision, failure to update care plans, and inappropriate discharge from hospital to a residential setting that could not meet his assessed nursing needs. There were missed opportunities to provide one-to-one care and to move the deceased to a safer environment, and the processes for authorising enhanced care were unduly delayed, prioritising resources over safety.

Court Disposition

Findings of missed opportunities and failings in care and treatment leading to death; recommendations for improved protocols and procedures.