Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0342, written 25 Jul 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Jul 2014 |
|---|---|
| Reference | 2014-0342 |
| Deceased | Charles Lawrence |
| Coroner | David Horsley |
| Coroner area | Portsmouth & South East Hampshire |
| Category | Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: - Manager - Alexandra Rose Care Home, 358 Havant Road, Portsmouth PO6 1NE 1 | CORONER lam David Clark Horsley, HM senior coroner for the coroner area of Portsmouth and South East Hampshire. 2 | CORONER’S LEGAL POWERS | 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 30" May 2013 | commenced an investigation into the death of Charles Cecil Lawrence, aged 89. The investigation concluded at the end of the inquest on 7" July 2014. The conclusion of the inquest was Mr Lawrence died due to an Accident. The medical cause of this death was: la: Spinal Cord Compression lb: Fractured Thoracic Vertebrae 2: Congestive Cardiac Failure and Pneumonia 4 | CIRCUMSTANCES OF THE DEATH On 2™ April 2013 Charles Cecil Lawrence fell in the residential home where he lived. He was visited by his GP who noted no apparent injury to Mr Lawrence. Mr Lawrence fell again later that day but his GP was not recalled. By 4" " April 2013 Mr Lawrence was in increasing distress and his condition deteriorated and his GP admitted him to Queen Alexandra Hospital, Portsmouth, where he was diagnosed as having sustained an untreatable spinal injury. He died at Queen Alexandra Hospital on 23 May 2013 at 06.40 hours. 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, — Alexandra Rose Care Home does not have a protocol of calling out a doctor to examine a resident who suffers more than one fall in a 24 hour period. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 19"" September 2014. |, 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Person, Mr Lawrence's daughter, lam 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. 25" July 2014 SIGNED BY/CORONER Ss
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.
oy. Pe - 0% C4 Q Alexandra Rose Residential Care Home 358 HAVANT ROAD, FARLINGTON, PORTSMOUTH PO6 INE Tel: (023) 9238 2944 Fax: (023) 9235 2352 Email: enquiries@alexandra-rose.co.uk 5" August 2014 Dear Mr Horsley Re: Inquest 7" July 2014 — Mr Charles Lawrence, Coroner’s Regulation 28 Report Further to your Regulation Report towards Alexandra Rose Care Home | am writing to you with the actions the Company are to take. The home has devised a ‘falls alert’ notification that will be faxed to the residents doctors surgery should they fall more than once over a 24 hour period. This has been agreed by the Drayton Medical Practice, although | have not as yet received any further response from the two other surgeries that the home uses. In this case the home will call these surgeries direct should a second fall arise within that period. We currently have over 25 residents registered at Drayton Medical Practice which is a substantial amount so | hope that you agree that this is the most important surgery to support us with this protocol. Further to this document, each resident now has this Protocol in their care plans under there mobility and falls risk assessments. | have enclosed a copy of the falls alert notification form, which | hope satisfies your requirements under note 5 of your report. Yours Sincerely Registered manager Company Number: 6850118 Registered Office: Waterfall Nursing Homes South Ltd., Caxton House, Borough Green, Kent TN15 8BQ,
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