Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0236, written 20 Jul 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Jul 2018 |
|---|---|
| Reference | 2018-0236 |
| Deceased | Ruth Perkins |
| Coroner | Emma Whitting |
| Coroner area | Coventry |
| Category | Care Home Health 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. The Rt Hon Matt Hancock MP, Secretary of State for Health and Social
Care
AT
The Department of Health & Social Care, 39 Victoria St, London, SW1H OEU
CORONER
1
I am Emma Whitting, Assistant Coroner, for the Coroner area of Coventry (sitting in
Warwickshire).
2
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/uksi/2013/1629/part/7/made
3
INVESTIGATION and INQUEST
On 4 April 2018 an investigation was opened into the death of Ruth Marian Perkin.
The investigation concluded at the end of the inquest on 11 July 2018. The conclusion
of the inquest was Accident.
4
CIRCUMSTANCES OF THE DEATH
The Deceased was admitted to Kenilworth Grange Care Home under a Discharge to
Assess (2DA) scheme from Warwick Hospital on 9 February 2018. Whilst at the
home, during the evening of 11 February 2018, she suffered an unwitnessed fall;
although she was not thought to have suffered any injuries at the time, the following
day she was noted by a visiting GP to have a shortened and externally rotated right
leg and to be experiencing a lot of pain on rotation of the right hip. She was
subsequently re-admitted to Warwick Hospital where she underwent a right dynamic
hip screw repair. Although she made an initial recovery, her condition deteriorated
thereafter, and she passed away on 29 March 2018; her death being certified at
9.00am that day.
5
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 could occur unless action is taken. In
the circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows –
(1) On admission to the Care Home, Mrs Perkin was assessed as follows:
Current Situation
“Ruth mobilises with a Zimmer frame, supported by one staff member. She is
at risk of falls MFRA tool for falls is in place”.
Expected Outcome
“To reduce the risk of falls for Ruth as much as possible”
1
(2) I was informed at the inquest that her MFRA risk of falls score at the time of
admission was 21.
(3) On 10 February 2018, only the day after her admission, Mrs Perkin was found
by staff on the floor of the corridor outside her room having apparently slipped
from the chair she had been sitting in. An incident form was completed and
her risk of falling was reviewed resulting in an increased MFRA score of
29. (The highest level is apparently 35). On 11 February at around 08.30 pm
during the evening, she was found on the floor again – this time in the lounge
at the Care Home and it appeared that she had again fallen from a chair in
which she had been sitting. The following morning, she complained of pain
and was admitted to hospital where she was found to have suffered a right
neck of femur and it was during that admission that she contracted
pneumonia and sadly passed away.
(4) I was informed by the Care Home Manager that if Mrs Perkin not suffered a
fracture and had been returned to the care of the Care Home after her second
fall, she would have suggested to the hospital that, in view of Mrs Perkin’s
tendency to act in disregard of care instructions, she was in fact most likely in
need of 1:1 care.
(5) I was informed that for the 20 residents at the Care Home there are 5 staff on
duty during the day, reducing to 3 staff at night, and my concern is that Mrs
Perkin’s discharge to the Care Home under the D2A scheme, when her
needs were still being assessed, actually placed her at an increased risk of
falls and death as a result.
6
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.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 14 September 2018. 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons daughter,
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.
9
DATE: 20 July 2018 SIGNED BY EMMA WHITTING
2
See every Prevention of Future Deaths report matching Care Home Health related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.