Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0151, written 19 Mar 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Mar 2024 |
|---|---|
| Reference | 2024-0151 |
| Deceased | Ian Dixon |
| Coroner | Lauren Costello |
| Coroner area | Manchester South |
| Category | Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Chief Executive of Stockport Metropolitan Borough Council
2. Chief Executive of Stockport Homes
1
CORONER
I am Lauren Costello, Assistant Coroner, for the Coroner area of South Manchester
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 5th July 2023 an investigation was commenced into the death of Ian Dixon,
then aged 72 years. The investigation concluded at the end of the inquest on
13th December 2023. At the end of the Inquest, I recorded a narrative
conclusion that Mr Dixon died as a result of traumatic brain injury following a fall
on a background of chronic alcohol excess with cerebellar atrophy.
The medical cause of death being:
1a) Traumatic Head Injury
1b) Chronic Alcohol Excess with Cerebellar Atrophy
4
CIRCUMSTANCES OF THE DEATH
Ian Dixon was a recovering alcoholic and had a history of falls. He had been suffering
from confusion, was unsteady on his feet and was awaiting a memory assessment.
Following an assessment by an Adult Social Care duty worker on 31st May 2023, a
decision was made to expedite the installation of an additional handrail on his staircase
to try to minimise the risk of falls. Prior to that meeting Mr Dixon had hurt his left arm
and hand, and the additional rail would mean that he could hold it with his undamaged
hand to stabilise himself on the stairs. The installation was to be completed through
Stockport Homes and the expectation was that this would be completed within 3 days
in accordance with the timeframe for an urgent request.
On 8th June 2023, Mr Dixon was found deceased following a fall at the bottom of the
stairs in his home. The fall caused an extensive skull fracture with an acute right sided
subdural hematoma.
A post-mortem examination showed chronic cerebellar atrophy, due to chronic alcohol
excess which likely caused his confusion and ataxia, leading to falls. A police
investigation confirmed that there was no evidence of suspicious circumstances or
third-party involvement.
At the time of his death no handrail had been installed. The inquest heard that there is
no process in place for the council to be notified when requested work is completed or
if there are any delays in work completion. The Inquest also heard that the work had
been marked as complete on the Stockport Homes system even though the handrail
had not been fitted.
1
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 will occur unless action is taken. In the
circumstances it is my statutory duty to report to you.
The MATTER OF CONCERN is as follows. –
(1) The Inquest heard that there is no policy in place governing the interaction
between Stockport Metropolitan Borough Council and Stockport Homes
following a request for the installation of equipment. This means that there is no
review undertaken to check whether urgent equipment has been installed,
urgent repairs completed or if there are delays/issues with the works requested.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you 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 14th May 2024. 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:
, on behalf of the Family.
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
Lauren Costello
HM Assistant Coroner
19.03.2024
2
2 responses 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.
Stockport Homes Cornerstone 2 Edward Street Stockport SK1 3NQ Ms Lauren Costello HM Assistant Coroner HM Coroner Manchester South By email 9th May 2024 Dear Ms Costello Re. Regulation 28 Report into the death of Ian Dixon I write in reference to the Regulation 28 Report into the death of Ian Dixon issued to Stockport Homes on the 19th March 2024. Stockport Homes were not asked to provide statements in respect of Mr Dixon’s death nor to attend the inquest. I would like to offer my sincere condolences to the family and friends of Mr Dixon. Stockport Homes Group (SHG) manage properties owned by Stockport Council (SMBC) which are let as social housing. Ian Dixon had been the tenant of a three- bedroom house Stockport Homes had limited contact with Mr Dixon however a system indicator was held on the Housing Management system that identified Mr Dixon as ‘Disabled – Other’. , Stockport since the 9th July 1990. I can confirm that Mr Dixon was to be provided with an additional handrail on the staircase, sadly the scheduled date of the installation was the day after Mr Dixon died. Some considerable time later in a separate event (possibly in preparing statements for the inquest), an administrative error was made when the Home Improvement Agency Project Leader responded to a query from the council’s Occupational Therapist to say that the work had been completed when in fact it hadn’t. This mistake was subsequently corrected by the individual concerned. In responding to the concerns you have raised about the processes and communications between SHG and SMBC in such circumstances, the following action is being taken: • Target timescales will be developed, agreed with SMBC and published by the end of May 2024. • The progress of major adaptations (e.g. stairlifts, level access showers etc) will be monitored via the monthly Adaptations Panel attended by both SMBC and SHG Officers. This meeting is already established. • A Sharepoint site will be developed providing access to both SMBC and SHG staff to monitor the progress of the installation and provision of minor adaptations (e.g. handrails, grab rails etc) - this will be in place by the end of May 2024. Thank you for raising your concerns with me and I trust that the actions detailed fully address them. Yours faithfully, Chief Executive
Chief Executive Town Hall Stockport SK1 3XE [Type here] 13 May 2024 Ms Lauren Costello HM Assistant Coroner HM Coroner Manchester South Dear Ms Costello Re. Regulation 28 Report into the death of Ian Dixon I write in reference to the Regulation 28 Report into the death of Ian Dixon issued to Stockport Metropolitan Borough Council (SMBC) on the 19th March 2024. In the first instance, I would like to offer my sincere condolences to the family and friends of Mr Dixon. SMBC provided a statement prepared by attended the inquest on 13 December 2023. (Team Manager - Adult Social Care) and presented evidence on the involvement of SMBC’s referral to for an additional stair handrail for Mr Dixon. The procedure involves our operational services referring to SMBC Equipment and Adaptations Team, who will then make a referral to Stockport Homes where arrangements for the necessary work will be made. At the time of Mr Dixon’s death, the formal level service agreements (SLA) in place did not specifically identify timescales for the installation of minor adaptations. It is dependent on the demand and capacity of the Handyperson Service. At the time the referral for Mr Dixon was received the Handyperson Service confirmed there was a backlog in work. a fast-track request is expected to take place within 3 working days and a routine request is expected to take place within 5 working days. Furthermore, there is no formal process with the SMBC Equipment & Adaptations Team for following up whether work has been carried out following a referral to Stockport Homes. To address these issues SMBC have liaised with Stockport Homes and have seen evidence of changes they will implement and will ensure we are active participants including: 1. Target timescales will be developed, agreed with SMBC and published by the end of May 2024. 2. The progress of major adaptations (e.g. stairlifts, level access showers etc) will be monitored via the monthly Adaptations Panel attended by both SMBC and SHG Officers. This meeting is already established. [Type here] 3. A Sharepoint site will be developed providing access to both SMBC and SHG staff to monitor the progress of the installation and provision of minor adaptations (e.g. handrails, grab rails etc) - this will be in place by the end of May 2024. In addition to the changes that will be made in collaboration with Stockport Homes SMBC will take the following actions: 1. Effective immediately, the worker in the Equipment and Adaptations team who has ordered the adaptation will be responsible for ensuring the request has been actioned /completed before the case is closed. 2. The named worker will be responsible for ensuring this is clearly documented on the SMBC case management system. 3. The Team Manager will have responsibility for oversight of this process and will retain the role of chair of the Major Adaptations Panel and has close links with Stockport Homes colleagues and will use this forum to monitor the changes described above. 4. In relation to all actions identified above, strengthening of the current SLA is required to ensure that both consistency of approach between both organisations and necessary targets are set and monitored. This will be completed by the end of June ensuring formal governance and sign off is agreed and understood. Thank you for raising your concerns with me and I trust that the actions detailed fully address them. Yours sincerely Chief Executive
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