Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0450, written 16 Oct 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Oct 2014 |
|---|---|
| Reference | 2014-0450 |
| Deceased | John Bird |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| 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.
Regulation 28: Prevention of Future Deaths report
John William BIRD (died 28.05.14)
THIS REPORT IS BEING SENT TO:
1.
Registered Care Home Manager
Hawthorn Green Care Home
82 Redmans Road
Stepney
London E1 3AG
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 2 June 2014 I commenced an investigation into the death of John
William Bird, aged 92 years. The investigation concluded at the end of the
inquest earlier today.
I made a determination that Mr Bird’s death came about as the result of
an accident, when he fell in his care home on the evening of Tuesday, 29
April 2014.
I recorded his medical cause of death as:
1a pneumonia
1b subdural haematoma
2 dementia and general frailty
1
4
CIRCUMSTANCES OF THE DEATH
Mr Bird fell at around 11.20pm, having gone to bed a couple of hours
earlier. A carer was close by and immediately came to his room to assist.
He was taken to hospital shortly thereafter, but later died from the injury
sustained.
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.
You were unable to detail in court the entirety of the falls risk assessment
you had undertaken for Mr Bird, because you did not bring the record of
the risk assessment to the inquest, despite the nature of Mr Bird’s death
and a written request from my coroner’s officer.
However, you were confident that you had assessed Mr Bird as being at
very high risk of falls, as a consequence of his level of cognitive
impairment coupled with his ability to walk without assistance. (This is, of
course, a very difficult combination.)
Yet the carer who found Mr Bird after his fall, did not appear to have any
familiarity with risk assessments. Even allowing for possible language
difficulties (the carer is not a native English speaker), he assessed Mr
Bird’s ability to mobilise unaided as “fine”, and did not see any particular
risks for him.
When I put the carer’s evidence to you in court, you told me that he
should know about the risk assessments. You later agreed in evidence
that, as manager of the care home, it is your responsibility to ensure that
all staff are familiar with risk assessments and the resulting care plan for
each resident.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you and Sanctuary Care Limited have the power to take such
action.
7
YOUR RESPONSE
2
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 15 December 2014. 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 following.
HHJ Peter Thornton QC, the Chief Coroner of England & Wales
Care Quality Commission for England
Chief Executive, Sanctuary Care Limited,
son of John Bird
Cameo House, Chamber Court, Worcester WR1 3ZQ
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
interest. You may make
he believes may
representations to me, the Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
it useful or of
find
9
DATE SIGNED BY SENIOR CORONER
16.10.15
3
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