Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0359, written 19 Nov 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Nov 2018 |
|---|---|
| Reference | 2018-0359 |
| Deceased | Beryl Walsh |
| Coroner | J Robinson |
| Coroner area | Manchester North |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. CEO of Beechwood Lodge Care Home, Meadow View, Norden, Rochdale CORONER lam Ms J Robertson, Assistant Coroner for the Coroner area of Manchester North CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroner’s and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. INVESTIGATION and INQUEST On the 11 June 2018 | commenced an investigation into the death of Beryl Ann Walsh. | concluded this inquest on 8 November 2018 and found that there were multiple missed opportunities by Beechwood Lodge Care Home to refer the deceased to the falls team, undertake appropriate risk assessments and to provide her with falls prevention equipment. CIRCUMSTANCES OF DEATH The deceased sustained catastrophic head injuries caused by an unwitnessed fall from her bed at Beechwood Lodge Care Home on 3 June 2018. This final fall led directly to the deceased’s death. 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:- 1. That there were multiple missed opportunities to identify the deceased as a person of high tisk of falls and to escalate her care by way of a referral to the falls team. Furthermore, there were multiple missed opportunities to provide the deceased with falls prevention equipment and to undertake falls risk assessments and care plans. | remain concerned that appropriate action to minimise the risk of deaths occurring in similar circumstances has not been taken by Beechwood Lodge Care Home. During the last 12 months of her life she had fallen on multiple occasions. However, she had not been referred to the falls prevention team and had not been provided with any falls prevention equipment. No care plans and falls risk assessments had been undertaken ‘= ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe each of you respectively 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 14" January 2019. |, 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 namely:- Family of the deceased. cac Adult Safeguarding at The Local Authority lam 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 from. 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. Date: UO Signed: (4 -/( - 1§ j
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.
BEECHWOOD LODGE Response to regulation 28 issued by Mrs Robinson, Coroner resulting from concerns raised at the inquest of Beryl Walsh (deceased) Completed b' CONCERN Multiple missed opportunities to identify the person was at high risk of falls and to escalate her care by way of a referral to falls prevention, multiple opportunities to provide the correct falls prevention equipment. Concern that appropriate action to minimise the ‘risks of deaths occurring in similar circumstances has been taken by beechwood. ACTION TAKEN The falls that BW sustained was over a 3 and half year period, the equipment what would be usually required was more of a risk to BW due to extremely poor eyesight so equipment for falls prevention was not appropriate due to trip hazards, however BW had good capacity so was able to use the call bell she had in place when she required assistance. 1. We have put more in robust risk assessments for residents who have had falls. We are documenting all conversations with relatives and professionals We have now put all new risk assessments in all care plans about safety equipment whether they use it or the reasons why they do and the reasons why they don't. | also have put in place a falls matrix, so | can monitor falls and do referrals to falls team when required. We will ensure all falls risk concerns are referred to appropriate professionals i.e. doctors and falls teams BW’s falls dates are as follows, 1* fall 2015 2™ fall 2016 3° fall 2017 4 5" 6" fall in 2018 BY WHOM /WHEN All actions have been completed with immediate effect by Home Manager.
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