Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0144, written 3 May 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 May 2017 |
|---|---|
| Reference | 2017-0144 |
| Deceased | Beryl Varcoe |
| Coroner | Anna Crawford |
| Coroner area | Surrey |
| Category | Community health care and emergency services related deaths |
| 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.
IN THE SURREY CORONER’S COURT
IN THE MATTER OF:
__________________________________________________________
The Inquest Touching the Death of Beryl Varcoe
A Regulation 28 Report – Action to Prevent Future Deaths
__________________________________________________________
THIS REPORT IS BEING SENT TO:
Rob Moran
Chief Executive
Elmbridge Borough Council
Civic Centre
High Street
Esher
Surrey
KT10 9SD
1 CORONER
Ms Anna Crawford, HM Assistant Coroner for Surrey
2 CORONER’S LEGAL POWERS
I make this report under paragraph 7(1) of Schedule 5 to The Coroners
and Justice Act 2009.
3
INQUEST
An investigation into the death of Mrs Varcoe was commenced on 4th
May 2016 and an inquest was opened on 21st September 2016. The
inquest was resumed on 21st March 2017 and concluded on 28th April
2017.
The medical cause of death was:
1a – Lobar pneumonia
The inquest concluded with a narrative conclusion.
4 CIRCUMSTANCES OF THE DEATH
Mrs Varcoe had a community alarm installed at her home address due to
concerns about her falling when she was alone. The alarm was installed
by Elmbridge Borough Council’s Community Alarms Service.
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The court heard evidence that the alarm system was a Chubb alarm and
comprised a base unit and a pendant to be worn around the service user’s
neck. In the event that the service user presses the pendant, the base unit
automatically dials a monitoring centre, which is staffed 24 hours a day.
The court was told that the pendant and the base unit communicate by
way of radio signals, which can potentially be interfered with by objects
such as walls, piping and electrical wiring.
The installer, who carried out both the initial installation of Mrs Varcoe’s
alarm on 13 May 2013, and the subsequent upgrade on 9 December 2015,
did not carry out any tests to ascertain whether Mrs Varcoe’s bedroom
was within the range of the base unit, which was located in one of her
reception rooms.
On the evening of 18 April 2016 Mrs Varcoe either fell or collapsed in her
bedroom. She repeatedly pressed the pendant but it did not activate the
alarm due to a number of impediments to the radio signal. As a result of
those impediments, her position was outside of the range of the base unit.
She remained on the floor until she was found by friends and family at
approximately 4pm on 19 April 2016. She was taken to St Peter’s
Hospital where she was diagnosed with pneumonia and chest sepsis,
which had developed as a result of the extended period that she had
remained on the floor. Despite treatment, her condition deteriorated and
she died at the hospital on 21 April 2016.
The period that Mrs Varcoe sent on the floor and the resultant delay in
her admission to hospital made a material contribution to her death.
5 CORONER’S CONCERNS
The court heard evidence from
, the head of Elmbridge Borough
Council’s Community Alarms Service, who told the court that the service
has 1,700 clients and two installation officers, who are responsible for
fitting and upgrading alarms in clients’ homes.
told the court that it was his expectation that the installation
officers carried out thorough range testing when fitting and upgrading
alarms, to check that the pendant was capable of activating the base unit
from all internal and external parts of a property.
The court also heard evidence from the particular installer who fitted and
upgraded Mrs Varcoe’s alarm. He gave inconsistent evidence with
regards to his practises in respect of range testing. However, having
2
considered the entirety of his evidence, the court is concerned that it was
his practice only to range test pendants in those parts of the service user’s
home, which they used most regularly and in which they felt most
vulnerable.
The court was told that the installation officer who fitted Mrs Varcoe’s
alarm has now retired. The court was also told that the Community
Alarms Service has developed a number of new procedures, which are to
be introduced imminently, with the aim of ensuring that thorough range
testing is documented at the time of each alarm installation or upgrade.
However, the court is concerned that a significant number of the service’s
clients currently have alarms, which were fitted prior to the introduction
of the new procedures and by the same installation officer who fitted Mrs
Varcoe’s alarm. As such there is a risk that those service-users may have
alarms which do not function throughout the entirety of their homes.
The MATTERS OF CONCERN are:
Elmbridge Borough Council’s Community Alarms Service has a
significant number of clients who currently have alarms, which may not
have not been thoroughly range-tested and may not function throughout
the entirety of the service-users’ homes.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I
believe that the people listed in paragraph one above have the power to
take such action.
7 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of its date; I
may extend that period on request.
Your response must contain details of action taken or proposed to be
taken, setting out the timetable for such action. Otherwise you must
explain why no action is proposed.
8 COPIES
I have sent a copy of this report to the following:
1.
2.
3.
, Mrs Varcoe’s son
, Head of EBC Community Alarms Service
, General Manager, Chubb Community Care
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4. The Chief Coroner
In addition to this report, I am 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 at the time of your response, about the release or
the publication of your response by the Chief Coroner.
Signed:
ANNA CRAWFORD
DATED this 3rd day of May 2017
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