Source · Prevention of Future Deaths

Ian Dixon

Ref: 2024-0151 Date: 19 Mar 2024 Coroner: Lauren Costello Area: Manchester South 2 responses identified · 2 indexed addressees View PDF

AI-generated concerns summaryThe coroner noted no policy existed between Stockport Metropolitan Borough Council and Stockport Homes for managing equipment installation requests. This meant there was no review process to confirm urgent equipment installation, repair completion, or to identify delays.

Date 19 Mar 2024
56-day deadline 14 May 2024 stated in the report
Responses identified 2 of 2
Alcohol, drug and medication related deaths

Coroner's concerns

AI summary
The coroner noted no policy existed between Stockport Metropolitan Borough Council and Stockport Homes for managing equipment installation requests. This meant there was no review process to confirm urgent equipment installation, repair completion, or to identify delays.
View full coroner's concerns
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.

Responses

2 respondents

Stockport Homes

Letter dated 9 May 2024 PDF
AI-classified response stance Action Planned
AI-generated response summary

• Target timescales will be developed, agreed with Stockport Metropolitan Borough Council (SMBC), and published by the end of May 2024. • The progress of major adaptations will be monitored via the established monthly Adaptations Panel attended by SMBC and Stockport Homes Group (SHG) Officers. • A Sharepoint site will be developed by the end of May 2024 to enable SMBC and SHG staff to monitor the progress of minor adaptations.

View full response
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 since the 9th July 1990. 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’.

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: Stockport Homes Cornerstone 2 Edward Street Stockport SK1 3NQ

• 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.

Stockport Metropolitan Borough Council

Local Authority
Letter dated 13 May 2024 PDF
AI-classified response stance Action Planned
AI-generated response summary

• Stockport Metropolitan Borough Council (SMBC) stated it would collaborate with Stockport Homes to develop and publish target timescales for adaptations and establish a Sharepoint site for monitoring progress by the end of May 2024. • SMBC confirmed that, effective immediately, the Equipment and Adaptations team worker ordering an adaptation would be responsible for ensuring its completion and documentation. • SMBC committed to strengthening the Service Level Agreement with Stockport Homes by the end of June to ensure consistency and monitoring of targets.

View full response
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 (Team Manager - Adult Social Care) and attended the inquest on 13 December 2023.

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.

Chief Executive Town Hall Stockport SK1 3XE

[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.

Report sections

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
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.

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Report details

Reference
2024-0151
Date of report
19 March 2024
Coroner
Lauren Costello
Coroner area
Manchester South

Responses identified

Responses identified 2 of 2
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 14 May 2024 (stated in the report).

Sent to

Stockport Homes
Stockport Metropolitan Borough Council

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