Source · Prevention of Future Deaths

Hazel Mayho

Ref: 2022-0340 Date: 26 Oct 2022 Coroner: Jason Pegg Area: Hampshire, Portsmouth and Southampton Responses identified: 1 / 1 View PDF

Frail, dementia patients at high risk of falls have unsupervised access to hazardous gardens due to open doors and distracted staff. The care home lacks effective exit control or alert systems to prevent vulnerable residents from entering alone.

Date 26 Oct 2022

56-day deadline 21 Dec 2022 est.

Responses identified 1 of 1

Care Home Health related deaths

Coroner's concerns

AI summary

View full coroner's concerns

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.

Responses

1 respondent

Westlands Care Home Other

13 Dec 2022 PDF

Action Taken

Westlands Care Home installed an additional beam to the garden doors to alert staff if a resident enters the garden without observation, addressing concerns about exit control. (AI summary)

View full response

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.

Report sections

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.

Circumstances of the death

Accident

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2022-0340
Date of report: 26 October 2022
Coroner: Jason Pegg
Coroner area: Hampshire, Portsmouth and Southampton

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: 21 Dec 2022 (estimated).

Sent to

Westlands Care Home

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.