Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0423, written 29 Nov 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Nov 2016 |
|---|---|
| Reference | 2016-0423 |
| Deceased | Doris Clarkson |
| Coroner | Andrew Tweddle |
| Coroner area | County Durham and Darlington |
| 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.
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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.
- fechiwed 14 |e] Soynltod FoUse ee CARE HOME & DAY CARE UNIT 16 New Lambton Village, Fencehouses, Co. Durham, DH4 6DE Tel: 0191 385 5768 Fax: 0191 385 2169 Email: care@lambtonhouse.com Web:www.lambtonhouse.com Date: 17 January 2017 Ref: AT.LO.2127.16 To: Coroner Mr A Tweddle LL.B We write in response to your Report pursuant to Regulation 28 of the Coroners (Investigations) Regulations 2013 relating to the death of Doris Clarkson (deceased). That report sets out that there is a concern regarding the removal of a pressure sensor from the deceased's bed after a specialist pressure relieving mattress was provided to her. The report recognises that a system of 15 minute checks was implemented after the pressure sensor had been removed, however in the Coroner's view, this change was inadequate and they felt that a pressure sensor mat should have been in place. Lambton House recognise that the Coroner has found that the simple provision of a pressure mat by a resident's bed will not eliminate their risk of falls, rather, it will simply alert staff that a resident is out of bed sooner and that this may lead to a reduction in the risk of fatalities. Lambton House confirm that there is no evidence to suggest that the absence of a pressure mat sensor in anyway contributed to the deceased’s fall nor did it impact on the severity of the injuries that she sustained as a result of the fall. Staff at Lambton House did recognise that a pressure sensor needed to be placed next to the deceased's bed and attempts were made to try to have a floor pressure sensor mat installed next to the deceased's bed. Unfortunately at that time this required a specialist contractor to attend to install the mat and incorporate it into the building's existing alarm system. That change could not take place that day. Unfortunately the deceased suffered a fall later that evening. It is now standard practice for pressure mats to be installed in all cases where a mattress is used that is incompatible with bed sensors. Steps are being taken to further minimise the risk that resident's face in situations such as this. Lambton House is currently in the process of phasing in through “Home Loans" the provision of air flow mattresses, where there has been an assessed need to aid pressure relief care. All new air flow mattresses are compatible with bed based pressure sensors. The aim is to eliminate the need for floor based pressure sensors, which in themselves can also create a risk of falls/trips. For those Service Users who are at risk of falls but do not require an air flow mattress a bed sensor is installed to reduce the risk. Yours sincerely Th _ y+ General Manager
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