Clara Freeman

On 13 March 2020 Mr lan Arrow, the senior coroner for Plymouth, South Devon and Torbay commenced an investigation into the death of Clara Ellen Freeman aged 87_ The investigation concluded at the end of the inquest on 19 February 2021.The conclusion of the inquest was the narrative conclusion; Clara Ellen Freeman died at 02.37 on 6 March 2020 on Monkswell Ward, Derriford Hospital, Plymouth. The Deceased suffered an unwitnessed fall at Hart Care Nursing and Residential Home at around 21.30 on 3 March 2020. The Deceased was discovered by care staff but developed medical complications as a consequence of a period of approximately 4 hours being kept on the floor of her room immobilised before an ambulance conveyed her to hospital. The Deceased eventually succumbed in hospital to the medical complications The cause of death was; a Acute Kidney Injury Rhabdomyolysis and Sepsis of Unknown Origin II Heart Failure, Atrial Fibrillation, Frailty and Hypertension

The Deceased suffered an unwitnessed fall at Hart Care Nursing and Residential Home and was found on the floor of her room on her left side, conscious, but in pain; The ambulance service was contacted at 21.48, which advised that there was heavy demand for the ambulance services at that time and the average waiting time was 2 hours_ Advice was given not to move the Deceased and to dial 999 if the Deceased's condition worsened. An ambulance arrived over 3.5 hours later at 01.23 during which time the Deceased was kept immobile on the floor: The care and nursing staff at the care home made 999 calls at 23.04 and 00.04 to ask when the ambulance arrive and advising that the Deceased was in intense pain and (at 23.04) that the Deceased's temperature and pulse had risen. Observations by the nursing staff also recorded that the Deceased's oxygen saturations reduced during the wait and that latterly the Deceased's colour appeared cyanosed. This information was not handed over in the telephone calls_nor was any concern raised about the risk to the Deceased being_kept immobile over such would

Tong period of time The information would have been important to the call handler to assess whether the Deceased's condition was deteriorating or whether to refer the matter to a clinical adviser and potentially reassess the category of response:

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action;