Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0036, written 3 Mar 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Mar 2017 |
|---|---|
| Reference | 2017-0036 |
| Deceased | Joan Rimmer |
| Coroner | Andre Rebello |
| Coroner area | Liverpool and Wirral |
| Category | Care Home Health related deaths · Community health care and emergency services related deaths |
| Organisation named | Liverpool Community Health NHS Trust |
| 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: REPORT TO PREVENT FUTURE DEATHS (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Liverpool Community Health NHS Trust –
2nd Floor Babbage House
Liverpool Innovation Park
Digital Way
Liverpool
L7 9NJ
2. Care Quality Commission -
CORONER
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I am André Rebello, Senior Coroner, for the area of Liverpool & Wirral Coroner Area
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.
INVESTIGATION and INQUEST
On 17th January 2017 I commenced an investigation into the death of Joan RIMMER
who was aged 92 years.
The investigation concluded at the end of the inquest on 3rd March 2017. The
conclusion of the inquest was
Ia Advanced Stage Dementia
II Fractured Neck of Femur (treated)
On the 3rd March 2017 the inquest concluded that Mrs Rimmer had died from an
Accidental death.
CIRCUMSTANCES OF THE DEATH
Joan Rimmer was 92 years of age with a past medical history of dementia, anxiety and
stress reaction. She was a resident of Croxteth Park Residential Home which is for
residents with early onset dementia. She was not on a deprivation of liberty
authorisation.by Liverpool DoLS team. On the 28th November 2016, she suffered an
unwitnessed fall. Joan had been left seated in her chair in her bedroom, whilst carers
collected what they needed to see to her personal care. On their return they found her
on the floor. A falls risk assessment was appropriately carried out. No doctor was called
but on 28th November 2016 she saw the community matron as she was complaining of
groin pain. He assessed recording his actions in the notes. His later witness statement
included additional information with regard to there being no physiological sign of a
fracture and that she did not consent to go to hospital for an x-ray. As a result of the
persistence of Mrs Rimmer’s neighbour a GP was called some 14 days. The GP
attended and assessed Joan on 12th December 2016. He reports that she was
shouting out but he felt that this was not due to her dementia, aware that she had
suffered a fall he referred her for an x-ray. On 13th December 2016 she was referred to
Aintree University Hospital and was found to have an intertrochanteric right hip fracture.
She underwent a hemiarthroplasty and post operatively she stopped eating and
drinking. Fluids and food were encouraged but eventually after discussion with family it
was decided to palliate Joan until she sadly passed away on 16th January 2017.
CORONER’S CONCERNS
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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. –
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Though there was no evidence that Mrs Rimmer’s death could have been avoided
by earlier diagnosis of her fractured hip – the court is concerned that the
Community Matron employed by Liverpool Community Health assessed her
physiological response to a fracture without taking any physiological readings
and further adjudged her to refuse to be x-rayed when a carer witness who was
present has explained that the extent of her dementia on the 29th November was
so severe she would not understand sufficient to give consent. This in part led to
a two week delay before her hip fracture was diagnosed. In another case such
standards of nursing could result in an avoidable death not being prevented.
The Matron did not attend the inquest due to leave however at the inquest the
family were advised by the home that he was retired – the court do not know
where the truth lies other than the elderly relatives were keen that the case was
concluded without further adjournment.
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ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you
[AND/OR your organisation] have the power to take such action.
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YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 5th April 2017. I, André Rebello 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
I have sent a copy of my report to the Chief Coroner and to the family of Mrs Rimmer
and Croxteth Park Residential Care Home and the CQC who may find it useful or of
interest.
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 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.
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André Rebello
Senior Coroner for the
City of Liverpool & the Wirral Area
Dated: 3rd March 2017
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