Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0290, written 6 Jul 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Jul 2015 |
|---|---|
| Reference | 2015-0290 |
| Deceased | Phyllis Broomhead |
| Coroner | Nicola Mundy |
| Coroner area | South Yorkshire (East) |
| 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.
Nicola Jane Mundy Senior Coroner for South Yorkshire (East District) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive Rotherham MBC Riverside House Main Street Rotherham S60 1AE | CORONER lam Nicola Jane Mundy, Senior Coroner for South Yorkshire (East District) 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. http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 12/06/2013 | commenced an investigation into the death of Phyllis Broomhead, 90. The investigation concluded at the end of the inquest on 06 July 2015. Cause of death: Traumatic left sided subdural haemorrhage The conclusion of the inquest was a Narrative conclusion: Phyllis Broomhead became a resident at Lord Hardy Court in December 2012 due to her dementia and general care needs. Despite multi-agency support she continued to suffer falls between 11 February 2013 and the time of her death. Three of these falls led to significant injuries. On 9 June she fell from her bed whilst trying to reach the toilet and sustained a head injury from which she died later that day CIRCUMSTANCES OF THE DEATH Mrs Phyllis Broomhead suffered from advanced brain disease (dementia) as a consequence of which she was admitted to the Lord Hardy Court EMI Residential Home on the 18th December 2012. The home cared for her general care needs and her dementia needs. Despite multi agency input Mrs Broomhead suffered several falls between the 11th December 2013 and her death on the 9th June 2013. Of the falls she suffered three of them were significant and all required hospitalisation. A Safeguarding Alert was raised at the time of the second significant injury which was exited the day of the alert, after enquiries had been made. It was felt all appropriate measures were in place and Mrs Broomhead returned to Lord Hardy Court. The falls continued until final fatal fall on 9 June 2013. Measures in place were not fully implemented. 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: — (1) Staff employed at Lord Hardy Court EMI Residential Home require further training with regard to: i. the head injury protocol, how this should be followed and the importance of doing so. Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DN1 3HS Tel 01302 320844 | Fax 01302 364833 ii. record keeping. iii. indicators and triggers to seek social worker input. (2) With regard to the Safeguarding team, subject to the impact of any subsequent legislation, the importance of ensuring that any initial screening process following a referral is sufficiently detailed and objective to facilitate the making of safe, sound and informed decisions with regard to any future action which might be indicated or indeed before exiting the process. Furthermore, | heard evidence that there were three types of home available; care homes, EMI care homes and nursing homes. For residents who are clearly continuing to be at high risk of serious injury, as was the case here, consideration should be given to introducing or expanding any local procedures or protocols to ensure closer scrutiny and monitoring of such residents’ progress. It seemed that although Mrs Broomhead was identified as being of high risk of falls, as it was felt that her needs didn’t amount to nursing needs there was no alternative but for her to remain in a care home. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you The Chief Executive, Rotherham Metropolitan Borough Council 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 31 August 2015. 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. COPIES and PUBLICATION y report to the Chief Coroner and to the following Interested Persons: | have also sent it to Messrs Kennedys solicitors and Capsticks solicitors - who may find it useful or of interest. | 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 r¢phesentations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. Signature Senior Corone Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DN1 3HS Tel 01302 320844 | Fax 01302 364833
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.
Rotherham p)
lita iy
Managing Director’s Office
Riverside House
Main Street
Rotherham
S60 1AE 2 EY
Tel: (01709) 822773 ee weet
E-mail: Stella.manzie@rotherham.gov.uk we ee
Email the Council for free @ your local library! ee
Our Ref: Direct Line: Extension: Please Contact:
SM/LH (01709) 822773 22773 Commissioner Manzie
11" September 2015
Ms N J Mundy
HM Coroner, South Yorkshire (East District)
Coroner's Court and Office
Crown Court
College Road
Doncaster
DN1 3HS
Dear Ms Mundy
RE: Phyllis Broomhead, (Deceased)
DOB: 05.03.1923 — DOD: 09.06.2013
On the 6 July 2015 you concluded the inquest into the death of Phyllis Broomhead. You
recorded a narrative conclusion and submitted a report under Regulation 28 to express
concerns about certain aspects of Mrs Broomhead’s care. Your report was received in to
the department on 26 July 2015.
You requested that the Local Authority respond to your report within 56 days outlining
details of action taken or proposed to be taken, setting out the timetable for action. The
original response time was extended to the 14! September 2015 by your office in a letter
to Jill Wetherall, Service Manager, Safeguarding Adults dated 1° September 2015.
Please find enclosed a detailed action plan of recommendations made under regulation
28, actions taken by Rotherham Metropolitan Borough Council, if these actions have been
achieved and a timescale to conclude any uncompleted actions. | hope these meet with
your approval.
Yours sincerely
suo and Managing Director
www.rotherham.gov.uk
ea ee re |
° 3 *COP'STOZEOTT uolsnjaude annetieu APU Jau0J09 94 ue|d UoRDe ZOSTOT\Jequiardas\ sTOZ\saHET\UONeNs|ULUPY
40 T aded BqwoWeBeUEW a91A195\uoWaBeUeW\3AILNDAXa JIIHO\(NSW) Weal Hoddns qusWaSeUeW\;9
“UOISIAOJd BSNOH-U| “pasinbad aye yey} suoioe jeipauiai
aseueyy oes Aue 40 pauojut st! JaSeuey) pasaysiZay
P8IQeIUNOIIY J9ddIJJO 94} S14} WIS “pamaiAad ase spsodad aued
JO sajdues wopues aiaym suaSeueyy BdIAaS
“STOZ Jaquiadeq “spuooas Aq 4No pales ase ssia ays Auojejn3ay
Aq jeuonesado Ayny aq pjnoys 249 34} JO BulOWUOW "S,Udd pue suoisimadns ‘s8ujaaw wea
waysAs WO Mau ay} Jo (Susaq JBWOJ ay} sazes0dsoou! ‘sauiwesgzoid Suluiesy ul pappaquia dayuny
pue) ino Joy ‘a219eId Jsaq yoiym Waisds | uaaq sey siyy aAamoy ‘DgWY 01 JUNOWeLed
ainsua 0} 8ulosu0 s! Bujuled} (VO) s.ueunssy AqyendD uaaq sAemje aney uoljeyuawuNndop ajeinooe
nq pajzajdwos si uose siyp M8U 94} $0 INO Bul|]OY JO adUeVOdLWu! ay} pue Buidaay pucoay “Buldaay puovay (1!
‘(S,Ydd) smainay
juawidojanag |euossag pue suoisiaiadns
[ENPIAIpul ‘sSuNaaw Wea} ul pappaquia
Uaaq osje aaey sjod0joid mau ayy “uanld
usaq sey dujules} asnoy-u| ‘pajuawajdwi
Uaaq aney |/eJ e SUIMO|jO} suoIDe
He 74} sansua 0} YiYs Ydea Jo pua ay) je
4S1P}I9YI BUY} JJO UBIs pue yOaY9 suosiAadns
YIYS “ssdiAsas jeUApIsal JgWY [}e Ssoude
NO paljO4 uaaq sey siy| *(sjeuoIssajoud “Os Bulop yo adueyodu ay}
“UOISIAOJd ASNOH-U| yyeay pasaysisa Aq padojanap) adejd ui ind Puke pamoj|oy aq pynous siyy
‘Jaseue| adiasas 4 Uae ose sey |je} & SuUIMO}}O) sudIZeriasqo MOY ‘|Od0JOId Aunful peay ays — (1
:ayqequn T SUBPIAI PUL P4OI9J 0} UO!}E]UaLUNIOp
MAN “|]2J © SUIMO|[OJ [OD0}01d pue 10] spuesas
“ao9eId Ysaq SUOUaAJd IU! Aiessad9u ay) YIM SaWoY aled yum Sulules sayyNy asinbau G uolDoas
ainsua 0} 3uloBu0 s} Suules} [12 woddns yey3 sjeuoissajoud aues yyeay SWOH [eljuapisay [AI WNOD ‘susauo9
3nq ajajdwod s! uonse siuy “panaiusy Aq padojanap ‘aoejd ut si Aayjod Aunfur peay ApseH pso7 ye padojdwa eS (T) $ J2U0I0D
PeayWoolg siyjAUd SuIA| JO Yeap ay} Suiyono} YOIsn}UOD aAie.eN s,ApUN|A| 4940405 0} spueSa, Ul Ue|g UOKOY
ST0Z/60/TT 9p:ST UolsJan jeuly [pUNoD YsnoJog uewodo.3a1\| YZnoJ10g weuysayi0y
vjOZ a8eg
X20P'STOZEOTT UOIsnjauos anjyeseu ApUnu Jauod09 a4 UR|d UO}39e ZOSTOTWequieidas\stoz\sieneT\UONeNsUIWPY
7B luaWaseUeW a2iA1as\yUaWs8eUEW\3ALLNIIXA JZIHD\(NSW) Wee] wWoddns yuawaeueW\:5
‘synpy Sulpsengayes
raiqequnosoy sao
“STOZ 4940390 Ul
saunpasoid synpy BuipuenSayes
AsIYSYJOA YINOS YOUN}
“STOZ 4840399 Wo. Aanljap
404} payqejauuiy s! Sujusery
“play sty) Ul suaysom
ysyeioads soy Suruiesy
Jang] nuye;d 0} Y8nosyy
4fe3s |e 10} ssauaueme
dIseq WO SjaAa| |e
ye Suluses) sapnjoul siyL
“ssauaseme aISeq puohaq
sulujesy Buipsensajes
MaU NO ||O1 OL
youne| ant Joy Apeay pue aniqoe Ajjuawind
ade aS9y} JUe!|dWOD JOY aed aq 0} Ua}UM
-9J pue pasiAas Udaq aAey Sainpadoid
sUnpy sulpsensajes asiysyso, yyNOS
“Juel|dwo9 39y a1eD aq 0} payepdn
pue pamaiaas uaaq sey dulules} Bulpsensajes
IV “STOZ eunr- judy ynoysnos4y
Sujuled) ssauasemy Buipuensayes Aiojepuew
UayeUapun arey je}s JUeAIaL ||
*a1}9e1d ul pappaquua 8ulaq 40 ssad01d ayy
Ul {IS S| pue STZ Judy T Uo pajyuawajduy}
SEM PY 24k) ay] ‘payxa aq ued Auinbua
7y UO!IIS e aJOJaq paljiUap! pue papsooas
Ajead aq 0] paau sawodyno yeu} sayiquap!
osje }| ‘Sulpsensajes UlyM Buryjew UuoIsiep
pue sassaz0id Sulpuensajes passaippe sey
PV BED BY JO 7 UOIDAS “PTOZ PV aed
ayi ul Ajnp Alojnje}s e si syjnpy 3uipsen3ajes
“ssa00id ay}
SUX B10Jaq Paapul JO payed!pul
9q 1Yysiw YydIYyM uo!De sunny Aue
0} puedas YUM suOIsi9ap pawiojul
pue punos ‘ayes yo Buiyew
ay} ajeyiaey 0} aAi~alqo pue
payleyap Ajjuaioyyns si jeuayas e
SUIMO}|O} SSado1d Buiuaads jeIyWUI
Aue Jey) 8ulunsua Jo aduevodu!
ay} ‘uo! e/s13a| JUanbasqns
Aue Jo yDeduu! ay} 0} yalqns ‘wea,
Sulpsensayjes ay} 0} spsesai yy (Z)
g uolpas
‘SUIa9U09
S$ JaU0IOD
“UOISIAOJd ASNOH-U}
raiqequnosoy 4ad1YyO
“*GTOZ 48q0190 Woy ade;d aye}
0} uldaq |JIM sMaiAas JaBeuey]
pasaysigay ‘pasuawiwos sey
ss920/d s8uljaaw jsasayuy ysag
* SAB|[Ef SU YBIY,, 104
SSI1 SUIOZUO ay} Japisuod
0} ade|d aye} 0} s8uNjaaWU
ysasaju] jsag ‘sjuapisas
xajdwod ,3uimalAa,,
YUM panjoaul AjjeuU0Oy aq
0} SuaBeueW| pasajsiZay
*sIy] adueie 0} Wed}
a}elsdosdde ay} 39e}U0D 0} pue payinbau si
juaplsad e JO MalAas pauuRjdun ue sayyaym
JUDWNDOP 0} S494e9 JOJUAS BY} JO} SI |
“4949 JOJUS 34} 0} AjJOaJIP Spa—au s,juapisas
® 0} sagueyp |e Odas Mou sjuejsisse ase)
“yndul JayJOM e190
49aS 0} $4933] pue suojzedipu|
peaywoog sijj|Ayd Suvi JO Yeap ay} Bulyono} UoIsN|DUOD aANesUeN S,APUN|| 480405 0} spread Ul Ue|g UY
ST0Z/60/TT 9¥:ST UOlsJaA jeuly
JpuNoD Yysnosog uewodo.ja|_J YSNOJOg WeYsJay,0Y
vjo€g ase
X90P'SLOZGOTT UoIsnjaucd anedeU ApUNU saUOs09 a4 UeId UO!IDe ZOSTOI\Jaquiaydas\stoz\sienET\UONeNSIUWpY
7B WaWEdeUEW) do1n19$\juaWeBeUEW\3ALLNDIX 43IHO\(NSW) Weal Woddns quawaseueW\:9
“salio8ayeo
aSay} UUM Ja}sI3a4
Ajuo ued suapiAoid asez
“IW3 Sulsinn
SuISuNN
IW eluapisay
leuapisey
SUOISIAOJd a4e9 NOY
vz pasaysigas yo sadAy
“aja}dwod si uoloe siyL py Ajjeuoneu ase asayy
UBYM aJed JO jaa] JaYSIY e 1OJ paau ay}
Ajiquap! mou pjnoys aoioesd ul aSueyo SIUL
“Ajayelsdosdde yaw Bulaq ave spaeu sayjaym
pue JUaWUOIIAUA ay) YUM pajeloosse
SSH 94 SSeuppe OFS! SIU! *s|Je} JO 4SLU YBIY
e aney Ayoeded y2e] OYM sjuapisay UayYM
Pasapisuod Mou ae UOISIDap JsaiaqU! Jsaq
94} pue spuenBayjes Ayaqi] Jo uoneaudaq
“Buluinbai se passasse uaaq pey
PeayWoodg Suir} 349 40 jana] ay} seM SIYL
“spaau Sulsinu passasse ou yum ynq ‘Ajuo
9429 /eluapisas Suiuinbas asoy} uey} spaeu
SulOpUOW pue ased Jay3Iy YIM S|eNpIAIpUl
JO} padojanap asam sawoy aed |IA/9
“BUIIXA B1OJaq SUOISIDIaP paWOJU!
SPW O} JayxeW UOISIDap ay} ajqeua Oo}
ade}s 3ujuaasds ay) SuLuNp 0} uayods ajdoad
pue sajep ‘pasiuljnsos uaaq avey sjuawnz0p
yeYM WUJUOD 0} 991}9eNd puepuejs
MOU SI BUIps0I9/ paylejap a1oyy “papsodad
pue painjdes s! Aausnof sawoysno ay aunsua
0} pue juel|dwod yoy aseD aq 0} pasaaul3ua
94 U9eq sey Ud!}e}UaLUNDOp Bulpuensajes
STOZ 4240390 U! asIYSYIOA YINOS ssoude
OU SEM 94a} Spaau BulsunuU 0}
qunowe },upip spaau Jay yey} 394
SPM UI Se ‘S{]e} JO ySI4 YBIY Jo Bulaq
Se paljiuap! sem peaywuooig sil
ysnouye iey} patuaas yj ‘ssasZoud
Sqapisad yons $o SuopuowW
pue Auiqnios Jasoj9 aunsua 0} uaAld
9q Pinoys uolesapisuod ‘aay
aseo ay} sem se ‘Aunful snolas
$0 ySIU y8Iy e aq 0} SuInuUOD
Asad aie OYM SjUapIsas
404 “Sawoy Sulsunu pue sawoy
94e9 |IAJ ‘SawoY ased ‘ajqejiene
sawoy Jo sadAq aaiy} noge
aouapiAa pseay | aOWJaYy Ny
peaywoolg sii|Aud SaIA JO Yeap ay} Suryono} uolsnjouOD anrjese
ST0Z/60/TT 9v:ST UOIsJaA jeul4
N S,Apun|q| 42U0105 0} spaeZai ul Ue|q UONDY
J!2UNOD Ysno1og Ueyodosja\j YSNoJ0g weysayujoy
3 X00P'STOZEOTT Uo}snjsu09 anneweu ApUNU J3U0I09 a4 URId UoNIe ZOSTOT\Lequiaidas\sTOZ\aNeT\UONeNSIULIPY
140 paced 7B juoWIABeUeW ao!n1as\quaWeseUVeW\3ALLNDIXA 4IIHD\(NSW) Wea Uoddns qusWeseueW\;9
(seo14as ynpy Jo peo EE :2|¢!suodsay 129440 Jo1Uas
“Ayjenuue yseaj ye Ajoy ny [e907
ay} Aq pue yjuow /uana Japiaoid ay} Aq
pameairad aie ased ul ajdoad jo suejd aed ty “aWOY sed e Ul
“pasinbay ulewuas 0} Jay JOJ IN aAeUaye
peaywoo.g sijAud Saj JO Yeap By} Surysno} uoIsnjouoD anijeseRl s,Apun|(| 42U0105 0} spueSau ul Ue}g UO
ST0Z/60/TT 9b:ST UOIssaA Jeuly [uno Yysno0g ueyjodo.ja\y YZno10g WeYsay}0Y
See every Prevention of Future Deaths report matching Care Home Health related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.