Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0283, written 31 Oct 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 31 Oct 2013 |
|---|---|
| Reference | 2013-0283 |
| Deceased | Wilhelmina Isobel Newton |
| Coroner | David Roberts |
| Coroner area | Cumbria (North & West) |
| Category | Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
David Ll. Roberts Ll.B
Lamplugh Road, Cockermouth. Cumbria.
5 D&E Lakeland Business Park
Her Majesty’s Senior Coroner
______
North and West Cumbria
CA13 0QT
hmcoroner.northwest@cumbria.gov.uk
Tel: (01900) 706902
Fax: (01900) 706915
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
RE: Wilhelmina Isobel Newton Deceased
THIS REPORT IS BEING SENT TO:
1. Mrs Diane Wood Chief executive Cumbria County Council Carlisle
2.
Corporate Director Adult and Local services Cumbria
County Council Carlisle
1
CORONER
I am David Ll. Roberts, senior coroner, for the coroners area of North and West Cumbria
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 13th May 2013 I commenced an investigation into the death of Wilhelmina Isobel
Newton, 98. The investigation concluded at the end of the inquest on 21st October 2013.
The conclusion of the inquest was Medical cause of death
1a) Subdural Haematoma
b) Fall
Conclusion:
On the 14th May 2013 in her room at Grisedale Croft Residential Home the deceased
was put into bed at about 03.00 hrs. At 04.30 hrs she shouted and was found to be lying
on the floor next to her bed. Later that morning she was found to be unrousable and was
admitted to Cumberland Infirmary where she died on 15th May 2013.
She died as the result of an Accident.
4
CIRCUMSTANCES OF THE DEATH
The deceased had a history of falls both before and after becoming a resident at
Grisedale Croft. She had fallen out of bed and banged her head at 04.30 hours. She was
not attended by a nurse until 09.45 hours shortly after which an ambulance was
summoned. She was prescribed regular aspirin.
S:\Statutory functions\Rule 43 and PFD\Post April 2013\Newton 2013-0283.doc
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. –
On the evidence heard it appeared there was no clear written plan , protocol or guidance
to the staff as to how they should respond to a potential head injury to an elderly resident,
particularly one receiving medication which had the potential to affect the blood’s clotting
ability: the absence of such guidance may apply to other residential homes operated by
the Council
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe your
organisation has the power to take such action, by way of a review of the procedures to
be followed when a resident is suspected of sustaining a head injury particularly when
that person is prescribed medication which affects the blood’s ability to clot.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 26th December 2013. I, 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 :-
The Chairman, The Adult Safeguarding Board
Public Protection Unit, Cumbria Constabulary
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
31st October 2013
D. LL. Roberts
HM Senior Coroner
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
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