Overview

• Assistant Coroner Helen Rimmer found “gross failures” in care at Leigh Moss Hospital’s Fern Ward that contributed to Margaret Mary Picton’s death from aspiration pneumonia in September 2022
• She concluded that sporadic and low-quality observations left Picton unmonitored for over an hour after staff failed to escalate clear risks
• CCTV footage showed staff mocking Picton’s paper-eating behaviour on at least five occasions without intervening or notifying senior clinicians
• Paramedics were locked out of the hospital and arrived without crucial information about her paper ingestion, a delay the coroner said likely hastened her death
• Mersey Care NHS Foundation Trust has accepted the verdict, issued a formal apology, launched a Patient Safety Incident Response Framework review and faces ongoing family demands for accountability and improvements