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Peter Howarth

Ref: 2020-0171 Date: 8 Sep 2020 Coroner: Chris Morris Area: Greater Manchester South Responses identified: 1 / 1 View PDF

The care home failed to conduct a robust investigation into a resident's fatal fall, missing crucial learning opportunities to prevent similar incidents for other residents.

Date 8 Sep 2020
56-day deadline 5 Jan 2021 est.
Responses identified 1 of 1
Care Home Health related deaths Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
The care home failed to conduct a robust investigation into a resident's fatal fall, missing crucial learning opportunities to prevent similar incidents for other residents.
View full coroner's concerns
1. The court heard evidence that, despite the fact Mr Howarth was injured in a fall at his care home which led to his final admission to hospital, Borough Care has not undertaken any investigation into the circumstances of that fall. Robust investigations into falls in care and nursing homes are essential with a view to considering whether or not there is any learning to be derived from the incident for the benefit of other residents with a view to reducing the risk of death arising from falls in similar circumstances. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I ­ believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 3rd November 2020. I, the coroner, may extend the period. Your response must tbontain details of action taken or proposed to be : taken, setting out the 'timetable for action. Otherwise you must explain why no action is proposed.

Responses

1 respondent
Borough Care Local Authority / Fire Service
29 Sep 2020 PDF
Action Taken

Borough Care implemented extra measures to review falls on a weekly/monthly basis after a previous PFD report, including weekly falls analysis, GP/falls clinic referrals for residents with more than 2 falls in 2 weeks, and monthly reviews. These measures have been discussed with CQC and their policy updated. (AI summary)

View full response
Dear Mr Morris

Thank you for your correspondence.

We had previously received a REG 28 on 28.11.19 relating to falls and have put extra measures in place to review falls on a weekly/monthly basis as a result.

Below is a time line of events:

Death of Andrew Hogg
06.05.19 Inquest of Andrew Hogg
06.10.19 REG 28 received
26.11.19 Manager Meeting
28.11.19 Reply to Coroner
02.01.20 Death of Peter Howarth
10.09.19 Inquest of Peter Howarth
07.07.20

At the Manager meeting on the 28th November 2019 we discussed the new procedures for reviewing falls in all Borough Care homes.

Managers must now complete a weekly falls analysis and detail all actions taken. If a resident has more than 2 falls in any period of 2 weeks a referral must be made to their GP or to the falls clinic.

Managers must also complete a monthy review to ensure the safety of all residents and hilight any trends that may be contributing to the falls within the home.

As you can see from the timeline above these extra measures were implemented after the inquest of Andrew Hogg. The additional measures were therfore not in place when Peter Howarth fell, but were in place before the inquest into the death of Peter Howarth.

All these measures have been discussed with CQC and our policy has been updated to reflect the extra analysis and actions.

I have attached the previous correspondence with the Coroner in relation to the earlier REG28, re falls. I hope this meets with your approval.

Please do not hesitate to contact me if your require any further information.

Regards

Head of Care

Report sections

Circumstances of the death
! Mr Howarth, who had a complex medical history, was admitted to hospital on 9th October 2019 having sustained injuries in a fall at Brynhaven Rest Home in Stockport. Whilst in hospital, Mr Howarth had anotherjfall, as a consequence of which he suffered a· fractured neck of femur which required surgery. I Mr Howarth died in hospital as a consequence of complex underlying health oroblems combined with iniuries sustained in a number of falls.

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Report details

Reference
2020-0171
Date of report
8 September 2020
Coroner
Chris Morris
Coroner area
Greater Manchester South

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: 5 Jan 2021 (estimated).

Sent to

Borough Care

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.