Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0340, written 26 Oct 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Oct 2022 |
|---|---|
| Reference | 2022-0340 |
| Deceased | Hazel Mayho |
| Coroner | Jason Pegg |
| Coroner area | Hampshire, Portsmouth and Southampton |
| Category | Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Westlands Care Home 1 CORONER I am Jason PEGG, Area Coroner for the coroner area of Hampshire, Portsmouth and Southampton 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. 3 INVESTIGATION and INQUEST On 30 May 2022 I commenced an investigation into the death of Hazel Lillian MAYHO aged 82. The investigation concluded at the end of the inquest on 26 October 2022. The conclusion of the inquest was that: The deceased died on 27th May 2022 at Winchester Hospice, Romsey Road, Winchester, Hampshire having suffered a brain injury on 19th May 2022 caused when the deceased fell in the garden of Westlands House Nursing Home, Headmoor Lane, Alton, Hampshire striking her head on a pathway. The deceased's frailty contributed to the death. 4 CIRCUMSTANCES OF THE DEATH Accident 5 CORONER’S CONCERNS During the course of the investigation my inquiries 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: (brief summary of matters of concern) The deceased was 82 years of age, was severely frail and suffered from dementia. The deceased was assessed as being at high risk of falls and had a reputation for wandering around the establishment. The deceased was not unique amongst the other residents in having such vulnerabilities. The lounge areas of the nursing home have doors leading to the garden. The garden has within it potential hazards to a vulnerable resident with a high risk of falls. The doors are kept wide open in warm weather. Whether a resident has entered the garden is only known if they are observed by a member of staff to do so. Members of staff are frequently distracted by other duties hindering their ability to fully and effectively observe vulnerable residents entering the garden. There is an absence of an effective exit control process to ensure that those with a recognised risk of entering the garden alone are prevented from doing so or an effective alert system is triggered when they do so. 6 ACTION SHOULD BE TAKEN Regulation 28 – After Inquest Document Template Updated 30/07/2021 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 December 21, 2022. 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 I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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 Dated: 26/10/2022 Jason PEGG Area Coroner for Hampshire, Portsmouth and Southampton Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
WESTLA JDS CARE H OME LTD Headmore Lane, Four Marks, Alton, Hampshire GU34 3EP www.westlandscarehome.co.uk enq11iries@westlandscarehome.co.uk 13th December 2022 FAO Jason Pegg (Area Coroner for Hampshire, Portsmouth and Southampton) Dear Jason, Please find below a response to Regulation 28: Report to Prevent Future Deaths. Action, we have taken with regards to the report into the sad accidental death is detailed below. Absence of effective exit control - An additional beam has been installed (8th December 2022) - this allows the doors to be open when required in hot weather at residents' request but it now allows for staff to know if someone has entered into the garden without them being observed should they be busy and not able to see if this has happened as mentioned in your report, this is a separate beam to the door opening and closing. This was sourced, quoted for and arranged to be installed via Saturn Call Bells who are also responsible for our Passive Infrared System. May I take this opportunity to point out that the report to prevent future deaths states that Westlands is a Nursing Home, we are a Residential Home. Should you require any further information, please do not hesitate to contact me. Yours Sincerely. (Registered Manager) A member ofHampshire Care Association Registered with the Care Quality Commission
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