Source · Prevention of Future Deaths
Samuel Brookes
Ref: 2025-0190
Date: 15 Apr 2025
Coroner: John Ellery
Area: Shropshire, Telford & Wrekin
Responses identified: 0 / 1
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A hospital discharged a patient without ensuring care arrangements were in place or that he could raise an alarm, leading to a critical delay in emergency assistance.
Date
15 Apr 2025
56-day deadline
10 Jun 2025
Responses identified
0 of 1
Coroner's concerns
A hospital discharged a patient without ensuring care arrangements were in place or that he could raise an alarm, leading to a critical delay in emergency assistance.
View full coroner's concerns
(1) The hospital arranged for Mr Brookes transportation home without rearranging the required care as set out in paragraph 4 above.
(2) There was no record or documentation or process to show or demonstrate that the care had been rearranged.
(3) The transport company were responsible for transportation only and were not required to notify either the hospital, or if known, the care company of Mr Brookes’ safe return. It proceeded on the basis or assumption that care would have restarted within 4 hours or sooner.
(4) Mr Brookes did not have his alarm pendant around his neck and nor was his mobile phone available (it was in another room). Accordingly when Mr Brookes got into difficulty he could not raise the alarm or call for help.
(2) There was no record or documentation or process to show or demonstrate that the care had been rearranged.
(3) The transport company were responsible for transportation only and were not required to notify either the hospital, or if known, the care company of Mr Brookes’ safe return. It proceeded on the basis or assumption that care would have restarted within 4 hours or sooner.
(4) Mr Brookes did not have his alarm pendant around his neck and nor was his mobile phone available (it was in another room). Accordingly when Mr Brookes got into difficulty he could not raise the alarm or call for help.
Report sections
Investigation and inquest
On 3 May 2024 I commenced an investigation into the death of Samuel Joseph BROOKES The investigation concluded at the end of the inquest on 24, 25 March & 9 April 2025 The conclusion of the inquest was; The deceased died following neglect to provide him his required care.
Circumstances of the death
Mr Brookes was discharged home from Russells Hall Hospital, Dudley on the 8 April 2024 where he had been admitted following a fall and long lie at home. The hospital arranged his transportation without rearranging his required care of two carers, four times a day. Mr Brookes, who was immobile and lived alone, was transported to his bed where he could not reach his pendant alarm nor his mobile phone, which was in another room. Mr Brookes was left unattended for two weeks until on the 22 April 2024 his grandson attended and found him unresponsive, wedged between his bed and the bedroom wall. An ambulance was called, sadly on arrival paramedics confirmed that Mr Brookes was deceased and his death was declared at 11:37 hours. It is not known when Mr Brookes died between the 8 & 22 April 2024.
Copies sent to
2. Weightmans LLP, Solicitors representing Dudley Group of Hospitals3. Outcome Care and Support4. Cartello AmbulanceTransport Company
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Report details
- Reference
- 2025-0190
- Date of report
- 15 April 2025
- Coroner
- John Ellery
- Coroner area
- Shropshire, Telford & Wrekin
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 10 Jun 2025.
Sent to
- Russells Hall Hospital