When Gerald Cragg died in Royal Oldham Hospital he was homeless and had just one pence left in his wallet. He was 82.
The official causes of his death are yet to be finalised, but those suggested by a Home Office pathologist are lengthy and reflective of the abject poverty Mr Cragg had been living in for years.
They include kidney and heart failure and low albumen levels in his blood – all potential indicators of severe malnutrition. Mr Cragg, a vulnerable pensioner with long-term health problems, had had to rely on his own trips to a food bank run by the Salvation Army to feed himself.
He was also found to have suffered some serious physical injuries before he died – a cut behind his ear and multiple broken ribs.
No definitive explanation for these injuries has been provided, but in the months leading up to his death numerous authorities raised concerns that Mr Cragg, and the friend who was putting him up at his flat in Oldham, were victims of “cuckooing”.
“Cuckooing” is the term used by police to describe criminals using the home of a vulnerable person to carry out illicit activities such as drug-dealing.
A Salvation Army volunteer reported seeing an unknown male taking money from Mr Cragg’s wallet after he went to collect his £182-a-week benefits from the Post Office.
i decided to spend a week in a coroner’s court to gain an insight into how much the crisis in Britain’s public services is contributing to deaths.
Rochdale, a court which covers Rochdale, Oldham, Bury and areas of north Manchester, was selected because it serves areas of relatively high deprivation, where people are most likely to be hit by any failure in public services.
This was the court that hit the national headlines in November when senior coroner Joanne Kearsley ruled that two-year-old Awaab Ishak died as a result of prolonged exposure to mould in his flat on a Rochdale housing estate.
But many other cases, just as tragic, go unreported. Those witnessed by i last week were not covered by any other media and iwas often the only other person present in the hearing other than the coroner and a police officer.
The Chief Coroner’s Office said the reports that it published ensured that “learning” from inquests were in the public domain and could be acted upon.
Mr Cragg’s sister Renee Fleming described how he had been diagnosed with epilepsy and a mental disorder as a child and had lived a “difficult” life that came to an end in desperately bleak circumstances.
The inquest into his death was one of dozens observed by i over the course of a week sitting in Rochdale Coroner’s Court.
Evidence heard during these hearings lifts the lid on the crumbling state of Britain’s public services as they struggle to cope with a multitude of crises including; pressure on the NHS, ambulance wait times, rising anti-social behaviour and unsolved crime, the spiralling cost-of-living and demand on local authority services.
It comes amid increasing concern at the number of excess deaths being recorded despite the threat of Covid-19 having receded.
i analysis of figures released by the Office for National Statistics show that between August 2022 and January 2023 there were 292,475 deaths in England, more than 31,000 higher than the five-year average which was 261,402.
There is no obvious explanation as to why this happening though some experts point to the excess deaths coinciding with a period of acute pressure on the NHS, with record numbers of people visiting A&E and waiting longer than they should be for an ambulance and increasing energy costs.
But it keeps happening. On Monday Rochdale Coroner’s Court will hear the tragic story of Barbara Bolton, an 87-year-old woman who died after developing hypothermia which may have been linked to her being unable to afford her heating bills. It will be only the latest in a long stream of cases heard concerning deaths that can be linked in some way to Britain’s current wider societal difficulties.
The court and its coroners sit in on the ground floor of a nondescript office bloc, hidden behind Rochdale’s central shopping centre. But it is in this plain modern building, and many like it across the country, that the extreme consequences of many people’s daily struggle to survive are being set out in cold, objective detail.
Last week, i was there to bear witness to a string of similarly tragic tales of lives that have come to an untimely end, to a grim snapshot of modern Britain.
They included the death of a baby, stillborn at home aged 28 weeks, in Oldham on last month. Police coroner’s officer Cathy Skeleton told the court that in the hours before the baby’s death the mother had repeatedly called Royal Oldham Hospital to report that she was bleeding and feeling pressure.
But midwives did not advise her to come to hospital, the court heard. “The mother is concerned that had she been told to go to hospital earlier the result could have been changed,” Ms Skeleton told the court.
Royal Oldham Hospital is carrying out its own investigation into the baby’s death, the court heard. Its maternity service is currently rated as “requires improvement” and according to the most recent CQC inspection in August last year, problems include a lack of staff training and insufficient numbers of midwives.
These are national problems. England has a shortage of more than 2,000 midwives and earlier this year, a report from the Care Quality Commission highlighted a concerning decline in the standards of maternity services across the NHS. Two in every five units are currently rated as either “requires improvement” or “inadequate”.
Meanwhile, ambulance wait times broke records in 2022, with people waiting 12 hours or more at A&E also at an all-time high. The case of one of those caught up in the chaos was also heard at Rochdale last week.
Terence Nolan, a retired joiner died on 22 November last year aged 81. He had vascular dementia and suffered a double hip fracture, while staying at Braeside Care Home in Rochdale, the inquest heard. Staff were unable to explain how his injuries came about, though there are records which suggest he suffered a seizure.
A doctor saw Mr Nolan on Friday, 14 October and recognised the hip fractures, the court heard. The care home called for an ambulance but none was available until the Saturday morning. When he finally arrived at hospital, surgeons decided to operate on one of the two fractures in a bid to relieve Mr Nolan’s pain before he was transferred to another care home for end of life of care where he died.
Speaking outside court, Mr Nolan’s family said he had had to wait more than 24 hours for an ambulance, despite being in considerable distress from the double hip fracture.
“He was such a quiet man,” said Mrs Nolan. “He deteriorated so fast in that week, they didn’t want to operate but they needed to he was in that much pain.”
While getting to hospital can be difficult at the moment, there can also be problems after you arrive.
Barbara Wilson, 82, was admitted into Royal Oldham Hospital with breathing difficulties on 28 December, Rochdale Coroner’s Court heard. Although she had been diagnosed with Alzheimer’s, her family said it was in the “early stages” and her subsequent death on 2 January came as a shock.
The court heard Mrs Wilson faced a “long stay” in A&E at the hospital before staff were able to find her a bed on a ward. While she was waiting in the emergency department, she was assessed as being at risk of a fall, but a care plan was not put in place, said coroner Cath McKenna.
Giving evidence at the inquest, Assistant Director of Nursing Andrew Thompson admitted this was a failing but said his internal investigation suggested would not have changed how Mrs Wilson was cared for. Around three hours after she was moved to the F9 ward, Mrs Wilson fell and sustained what would turn out to be a “catastrophic” head injury, the court heard.
No staff witnessed the fall but a coroner ruled that it was “more likely than not” that Mrs Wilson hit her head on a drip stand that had been left next to the neighbouring patient. “That drip stand should have not have been there at that time,” Ms McKenna said.
A CT scan revealed a bleed on the brain but a specialist surgeon did not believe Mrs Wilson was able to undergo a procedure, the court heard. Her family were told she was being moved onto end of life care but daughter-in-law Christine Wilson told the coroner they were unable to have Mrs Wilson moved to a side room for her final hours.
Tony Lloyd, the veteran Labour MP for Rochdale, is unsurprised by i‘s findings at the town’s coroner’s court.
“What we are talking about is the changing face of Britain,” he said.
“It is the impact of austerity over the years and how the level of public services has been run down… And I think the gap is growing between the more affluent and the poorest.
“However you explain it, whatever stone you turn over, people will essentially live less happier lives than they would if they were born in more affluent parts of the country. And that can’t be right in modern Britain.
“Ambulances used to run on time, A&Es used to admit people relatively quickly, we didn’t have doctors and nurses up in their necks in it to the extent they’re taking industrial action, each of these is a little thread in the fabric of society that is being strained and broken.”
The MP wants to see a national system for recognising the failures that emerge through coroners’ findings.
“This was one week at Rochdale,” he said. “What happens for the other 51 weeks of the year across the nation and is that all collected in some way?”
The government was contacted for comment.
Instead her family found themselves having to help other patients on the ward.
“Me and Graham [Mrs Wilson’s son] were assisting two patients because nurses were not responding to their shouts for help,” said Christine Wilson. “[The patients] could see us all through the night and they were asking ‘can you help? Can you get me some food?’”
Mr Thompson said he did not believe there had been staffing problems at the time but he apologised to Mrs Wilson’s family for their experience.
“We don’t want relatives to have to intervene like that,” he said. “You should have been offered more support and I can only apologise.”
More than 7 million people are now waiting for NHS procedures in England – a figure that has been on the rise for years but which ballooned as a result of the pandemic – and the problem was also among the circumstances surrounding death cited at Rochdale Coroner’s Court last week.
Evelyn Murphy, 89, from Crumpsall, north Manchester, was in reasonable health shortly before she died on 25 November last year, her family said. She was still able to be her husband’s carer but was waiting a procedure on her heart.
“She had been waiting for an operation since October,” said Mrs Murphy’s daughter Marie Dawson.
“It took over a month because of the backlog that they had.”
Following her operation at North Manchester General Hospital, Mrs Murphy was discharged to Crumpsall Vale, a care unit for rehabilitation on the expectation she would be able to return home.
But on 27 October she suffered an unwitnessed fall from her bed, the court heard. A senior sister realised she had fractured her hip, but surgeons decided Mrs Murphy was not well enough for surgery, and she was moved to end of life care and died on 25 November. Heart failure was listed as one of the causes of her death.
Solicitor Kelly Darlington, has worked on inquests for more than a decade and has seen a noticeable rise in the number of cases reaching coroner’s court.
The partner at Manchester law firm Farleys, says people “fall through the cracks”. “If you look at NHS deaths it can be due to how overwhelmed the NHS is, resources, not enough doctors and nurses on the ground and then because they are overworked, perhaps things get missed that wouldn’t usually get missed,” she said. “I think it’s just a culmination of everything.”