Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0487, written 11 Nov 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Nov 2014 |
|---|---|
| Reference | 2014-0487 |
| Deceased | Mary Hallworth |
| Coroner | Joanne Kearsley |
| Coroner area | Manchester South |
| Category | Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Home Instead Senior Care (High Peak) The Stables, 48B Buxton Road, High Lane, New Mills, Stockport, SK6 8BH 1 | CORONER | am Joanne Kearsley, Area Coroner, for the coroner area of South Manchester 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 26" March | commenced an investigation into the death of Mary Hallworth date of birth 17.09.1915. The investigation concluded on the 18" July 2014 and the conclusion was one of Accidental Death. The medical cause of death was 1a) Bronchopneumonia 1b) Fractured left hip and I!) Asthma and Hypertension. 4 | CIRCUMSTANCES OF THE DEATH The circumstances leading to the death of the deceased are as follows:- The deceased was a frail, elderly lady who was living at her home address. She was practically immobile and required assistance with all her daily needs. She was prone to falls from her bed. On the 18" March 2014 at 08.25am the deceased was found bya carer on the floor of her bedroom. She was complaining of pain on her left side. The carer sought assistance from the office as she was not medically trained. Following advice the carer left Mrs Hallworth when a family friend was contacted and arrived at the property. She was then lifted ‘in a fireman’s lift’ and placed on the bed. She was still in pain and was given liquid paracetamol. 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. — - Despite the deceased being in pain and having fallen, no medical attention was sought or considered for a period of 24 hours. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 6 January 2015. |, 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 Chief Coroner and to the following Interested Persons namel | 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/abgut the release or the publication of your response by the Chief Coroner. Date: 11 November 2014 Joanne ley, HM Ar oroner Manchester South je
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