Source · Prevention of Future Deaths

Sylvia Gibson

Ref: 2022-0342 Date: 27 Oct 2022 Coroner: Jeremy Chipperfield Area: County Durham and Darlington Responses identified: 1 / 1 View PDF

Critical information about a resident's fall was not conveyed by care home staff to a visiting doctor, highlighting a lack of robust systems for sharing important patient details with healthcare professionals.

Date 27 Oct 2022
56-day deadline 22 Dec 2022
Responses identified 1 of 1
Care Home Health related deaths

Coroner's concerns

AI summary
Critical information about a resident's fall was not conveyed by care home staff to a visiting doctor, highlighting a lack of robust systems for sharing important patient details with healthcare professionals.
View full coroner's concerns
Although staff at Lambton House Care Home were aware of her fall in the early hours of 17th August, and this information was handed over to other staff, the same information was not conveyed to the doctor who visited Sylvia (being “not her usual self”) at around lunchtime that day. It appears that no systems were in place to ensure that important information is conveyed to healthcare professionals. Evidence does not suggest that this communications failure contributed to Sylvia’s death.

Responses

1 respondent
Lambton House Other
3 Nov 2022 PDF
Action Taken

Following a fall incident, Lambton House implemented immediate actions: mandatory full documentation of falls, visual checks by senior staff, recording of observations (O2 sats, pulse, BP, temp, resps), contacting appropriate medical personnel, and following documented advice. Senior staff received supervision on communication and documentation. (AI summary)

View full response
Subject: [EXTERNAL]:Notification of Inq Conclusion for PIPs GIBSON S 18082022 Date: 03 November 2022 16:22:20 CAUTION: This email originated from outside of the organization. Do not click links or open attachments unless you recognize the sender and know the content is safe.

In response to your report in relation to S Gibson, dated the 27/10/2022, the following actions have been implemented with immediate effect Any witnessed or unwitnessed fall must be fully documented. The service user is to be visually checked by the senior care manager on duty. All observations are to be completed and recorded (O2 sats, Pulse, BP, Temp, Resps). The appropriate medical persons are to be contacted at the time and informed of witnessed/unwitnessed fall. (999, 111, Recovery at Home, GP.) All observations will be passed over to the relevant clinician for advice. The advice given will be documented and followed. The above actions must be followed in the event of any fall. All senior members of staff will receive a supervision on the importance of communication and documentation. They have also received a copy of the above actions. Regards

Registered Manager Lambton House New Lambton Fencehouses Houghton le Spring DH4 6DE

Report sections

Investigation and inquest
On Second September 2022 I commenced an investigation into the death of Sylvia GIBSON, aged 96. The investigation concluded at the end of the inquest on 27th October 2022. I found that the deceased died as a result of natural causes to which accidental injuries contributed.
Circumstances of the death
Sylvia sustained an unwitnessed fall in the early hours of 17th August 2022 thereby sustaining injuries. These injuries were not reported to the attending medical practitioner.

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Report details

Reference
2022-0342
Date of report
27 October 2022
Coroner
Jeremy Chipperfield
Coroner area
County Durham and Darlington

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 22 Dec 2022.

Sent to

Lambton House LTD

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