Hampshire County Council
Local Authority / Fire Service
Action Taken
Hampshire County Council updated its "falls protocol" in line with current NICE guidance, clarifying that staff should contact 999 or 111. Additionally, staff will now participate in a standalone learning module on falls management, including head injury risk. (AI summary)
View full response
Dear Mr Pegg,
Report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 dated 5 January 2021 in connection with the investigation into the death of Arthur Edward JOHNSON.
Further to the above report of the inquest concluding “accident” and medical cause of intracerebral haemorrhage, I have noted your concerns relating to the response by staff at Oakridge House Residential Home and perceived shortcomings in the management of falls and suspected head injury.
I have now had the opportunity to follow up the matter further and am able to provide additional information that may not have been previously presented during your investigation, for which I apologise.
I understand that when you requested the documentation for Mr Johnson’s inquest, you received only part of the current “falls protocol”. As a result of your recommendations the entire protocol has been reviewed and updated in line with current NICE guidance. This clearly directs staff to contact 999 or 111. The revised protocol is attached and I trust addresses the concern relating to the clarity of practice guidance.
Regarding staff training, previously staff were trained in how to respond to head injury events during our “Emergency Aid” course. Following your comments, this has been reviewed. Although staff working in a residential setting are not clinically trained, they will now be required to participate in a standalone learning module designed specifically to focus on falls management issues, including risk of head injury. This will compliment other practice guidance for example risk assessment and risk management plans for mobile elderly people in a communal living setting.
Jason Pegg Area Coroner for Hampshire, Portsmouth and Southampton Castle Hill, The Castle, Winchester, SO23 8UL Enq ui ri es to
My r ef er en ce
Dir ect li n e
Yo u r r ef er en ce
Da te 23 February 2021 E-ma il
Adults’ Health and Care 3 r d Floor, Elizabeth II Court West Sussex Street Winchester Hampshire SO23 8UQ Telephone Telephone
I apologise again that you were not provided with all the relevant information at the time of your initial request. I trust this letter will reassure you that the matter has been taken seriously and as a result revised guidance and training arrangements established.
Report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 dated 5 January 2021 in connection with the investigation into the death of Arthur Edward JOHNSON.
Further to the above report of the inquest concluding “accident” and medical cause of intracerebral haemorrhage, I have noted your concerns relating to the response by staff at Oakridge House Residential Home and perceived shortcomings in the management of falls and suspected head injury.
I have now had the opportunity to follow up the matter further and am able to provide additional information that may not have been previously presented during your investigation, for which I apologise.
I understand that when you requested the documentation for Mr Johnson’s inquest, you received only part of the current “falls protocol”. As a result of your recommendations the entire protocol has been reviewed and updated in line with current NICE guidance. This clearly directs staff to contact 999 or 111. The revised protocol is attached and I trust addresses the concern relating to the clarity of practice guidance.
Regarding staff training, previously staff were trained in how to respond to head injury events during our “Emergency Aid” course. Following your comments, this has been reviewed. Although staff working in a residential setting are not clinically trained, they will now be required to participate in a standalone learning module designed specifically to focus on falls management issues, including risk of head injury. This will compliment other practice guidance for example risk assessment and risk management plans for mobile elderly people in a communal living setting.
Jason Pegg Area Coroner for Hampshire, Portsmouth and Southampton Castle Hill, The Castle, Winchester, SO23 8UL Enq ui ri es to
My r ef er en ce
Dir ect li n e
Yo u r r ef er en ce
Da te 23 February 2021 E-ma il
Adults’ Health and Care 3 r d Floor, Elizabeth II Court West Sussex Street Winchester Hampshire SO23 8UQ Telephone Telephone
I apologise again that you were not provided with all the relevant information at the time of your initial request. I trust this letter will reassure you that the matter has been taken seriously and as a result revised guidance and training arrangements established.