Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0134, written 6 Apr 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Apr 2016 |
|---|---|
| Reference | 2016-0134 |
| Deceased | Vincent Smith |
| Coroner | Derek Winter |
| Coroner area | Sunderland |
| 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.
Derek Winter DL Senior Coroner for the City of Sunderland | REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: - Village Nursing & Care Home @ Murton Wellfield Rd Murton Seaham SR7 9HN CORONER Tam Derek Winter, Senior Coroner for the City of Sunderland. CORONER’S LEGAL POWERS I 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/S/paragraph/7 INVESTIGATION and INQUEST On 16" November 2015 I commenced an investi gation into the death of Mr Vincent Smith, aged 80 years. The investigation concluded at the end of the Inquest on 1" April 2016. The conclusion of the Inquest was Accident Contributed to by Neglect. CIRCUMSTANCES OF THE DEATH Mr Smith was admitted to the Village Nursing and Care Home Murton on 6" November 2015. He had unwitnessed falls on 7" and 8°" November, which led to his admission to Sunderland Royal Hospital on 9" November 2015. On 15" November 2015 Mr Smith died from a head injury and bilateral pneumonia. 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. — Whilst at the Village Nursing and Care Home members of staff were to monitor and support Mr Smith’s mobilisation. Although being on notice after his first fall, there were insufficient steps taken to assess and act upon Mr Smith’s vulnerability. Civic Centre, Burdon Road, Sunderland, SR2 7DN Tel OF91 5647843 | Fax 01915537803 | DX 60729 Sunderland www.sunderland.gov.uk/coroner Evidence suggested that there ought to be: - 1) areview of the Home's formal written admissions policy to include verification of the information provided about the suitability of a prospective resident for admission, as well as 2) a review of the Home’s formal written falls risk assessments policy and associated training for staff, together with any other steps that ought to be taken to mitigate the risks of falls. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I 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 4" June 2016. 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 T have sent a copy of my report to the Chief Coroner and to the following Interested Persons: - « Family e cac 1am 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. Dated this 6" day of April 2016 | Signature y, LD WS Senior Coroner for the City of Sunderland
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