Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0146, written 2 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 | 2 May 2017 |
|---|---|
| Reference | 2017-0146 |
| Deceased | Ida Toole |
| Coroner | Thomas Osborne |
| Coroner area | Milton Keynes |
| 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.
Thomas Ralph Osborne Senior Coroner for Milton Keynes REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT 10: Strategic Director, Excel Care CORONER | am Thomas Ralph Osborne, Senior Coroner for Milton Keynes . 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 16/01/2017 | commenced an investigation into the death of Ida Jean Toole, ages 82 . The investigation concluded at the end of the inquest on 2"? May 2017. The conclusion of the inquest was that she died as the result of an accident. CIRCUMSTANCES OF THE DEATH Mrs Toole suffered an unwitnessed fall at Water Hall Care Centre on the 10th January 2017 and suffered a head injury. She died at Milton Keynes Hospital on the 14th January 2017. Her cause of death was given as 1a) Pneumonia 2) Acute on Chronic Subdural Haemorrhage 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. — During the course of the evidence | was told that Mrs Toole did not have a sensor mat alongside her bed despite having been assessed as a high risk of falling. The reason for this, | was told, was due to the fact that Mrs Toole had mental capacity. The policy for the provision of sensor mats to high risk residents should be urgently reviewed. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | 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 27" June 2017. |, 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons e Care Quality Commission e The family of Mrs Toole | 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 who he believes may find it useful or of interest. oner, at the time of your response, about the
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