Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0319, written 1 Dec 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Dec 2013 |
|---|---|
| Reference | 2013-0319 |
| Deceased | John William Tugwell |
| Coroner | Martin Fleming |
| Coroner area | Surrey |
| Category | Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
IN THE SURREY CORONER’S COURT IN THE MATTER OF: __________________________________________________________ The Inquests Touching the Death of John William Tugwell A Regulation Report – Action to Prevent Future Deaths __________________________________________________________ THIS REPORT IS BEING SENT TO: Coombe Dingle Nursing Home, 14 Queens Park Road, Caterham, Surrey. CR3 5RB 1 CORONER Martin Fleming ADC Surrey 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 20 of the Coroners (Investigations) Regulations 2013 3 INVESTIGATION and INQUEST On 16th April 2013 I opened an inquest into the death of John William Tugwell who, at the date of his deaths was aged 79 years. The inquest was resumed and concluded on 22nd November 2013 I found that the cause of death to be: ‐ 1a. Bilateral lobar pneumonia 1b. Acute subdural haemorrhage and cortical contusions I concluded with Accidental Death. 4 CIRCUMSTANCES OF THE DEATH On 6th April 2013 Mr John William Tugwell was found at the bottom of the stairs following an unwitnessed fall at the nursing home where he was a resident. At the hospital he was found to have sustained skull fractures and an extra cranial scalp haematoma. Very sadly he was not considered fit for surgery and he subsequently succumbed to his injuries on 9th April 2013. RT3763 1 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed a matter that gave rise to concern and which, in my opinion, there is a risk that future deaths could occur by reason thereof unless action is taken. The MATTER OF CONCERN is as follows. – Although Mr Tugwell was clearly a falls risk given his documented history of previous falls at the home, he was allowed unsupervised access to the two sets of stairs at the home. I would be grateful if you could re consider the appropriateness of allowing such vulnerable and unsupervised residents access to the stairs given the potential for serious injury. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that Coombe Dingle Nursing Home have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of its date; I may extend that period on request. Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise you must explain why no action is proposed. 8 COPIES I have sent a copy of this report to: Surrey Police CQC Surrey Safeguarding Adults Chief Coroner Coroners Society for England and Wales RT3763 2 9 DATED this 1st December 2013 RT3763 3
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