Source · Prevention of Future Deaths
Eldine Lashley
Ref: 2021-0308
Date: 16 Sep 2021
Coroner: Graeme Irvine
Area: East London
Responses identified: 0 / 1
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The patient's mobility care plan was not updated to reflect increased observation needs, and staff progress notes inaccurately recorded the frequency of checks performed.
Date
16 Sep 2021
56-day deadline
11 Nov 2021 est.
Responses identified
0 of 1
Coroner's concerns
The patient's mobility care plan was not updated to reflect increased observation needs, and staff progress notes inaccurately recorded the frequency of checks performed.
View full coroner's concerns
1. Mrs Lashley's mobility care plan was not updated in response to developments in her care needs - specifically the need to observe her more frequently than once per hour.
2. Progress notes created by nursing and care staff did not accurately reflect the frequency of checks carried out on Mrs Lashley.
2. Progress notes created by nursing and care staff did not accurately reflect the frequency of checks carried out on Mrs Lashley.
Report sections
Investigation and inquest
On 18th April 2021 I commenced an investigation into the death of Eldine Loretta Lashley aged 82 years. The investigation concluded at the end of the inquest on 2nd September 2021 . The conclusion of the inquest was that Mrs Lashley died from:
1.a Subdural Haematoma; II. Advanced dementia, Type 2 diabetes mellitus, Chronic kidney disease, Hypertension A short form conclusion of accidental death was arrived at.
1.a Subdural Haematoma; II. Advanced dementia, Type 2 diabetes mellitus, Chronic kidney disease, Hypertension A short form conclusion of accidental death was arrived at.
Circumstances of the death
5 7
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Report details
- Reference
- 2021-0308
- Date of report
- 16 September 2021
- Coroner
- Graeme Irvine
- Coroner area
- East London
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: 11 Nov 2021 (estimated).
Sent to
- Cherry Orchard Nursing Home