Source · Prevention of Future Deaths

Shirley Froggett

Ref: 2021-0065 Date: 1 Mar 2021 Coroner: Robert Hunter Area: Derby and Derbyshire Responses identified: 0 / 1 View PDF

New Lodge Nursing Home lacked robust systems to ensure staff compliance with patient care plans, policies, and protocols.

Date 1 Mar 2021
56-day deadline 26 Apr 2021
Responses identified 0 of 1
Care Home Health related deaths

Coroner's concerns

AI summary
New Lodge Nursing Home lacked robust systems to ensure staff compliance with patient care plans, policies, and protocols.
View full coroner's concerns
The MATTERS OF CONCERNS are as follows: On the evidence heard at inquest I was not satisfied that New Lodge Nursing Home had any robust systems in place to ensure compliance with care plans, policies and protocols.

Report sections

Investigation and inquest
On 23/11/2018 I commenced an investigation into the death of Shirley FROGGETT aged 84. The investigation concluded at the end of the inquest on 19 February 2021. The conclusion of the inquest was: I a Bronchopneumonia I b Fractured Left Femur (Operated 25/09/2018) I c II Osteopenia
Circumstances of the death
Shirley Froggett died on the eighth of November 2018 at the Old Lodge Nursing Home, Sandypits Lane, Etwall, Derbyshire. Conclusion of the Coroner as to the death: Shirley Froggettt died of bronchopneumonia resulting from a fractured left femur which was sustained in a fall from a wheelchair in a Nursing Home. Despite a care plan being in place, requiring Mrs Froggett to be secured in her wheelchair, to prevent her from falling, the lap-strap was not applied as it was missing a buckle. The continued use of the wheelchair and the non-observance of the care plan were gross failures. As such Mrs Froggett died from an accident contributed to by neglect.
Action should be taken
7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 26 April 2021. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons The Care Quality Commission and the son and daughter-in-law of the deceased. and to the Local Safeguarding Board (where the deceased was 18). I have also sent it to …………………………………………………………………………………………………………………… who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. Robert HUNTER Senior Coroner for Derby and Derbyshire Dated: 01 March 2021

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Report details

Reference
2021-0065
Date of report
1 March 2021
Coroner
Robert Hunter
Coroner area
Derby and Derbyshire

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: 26 Apr 2021.

Sent to

New Lodge Nursing Home

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