Source · Prevention of Future Deaths
Eileen Pollard
Ref: 2020-0053
Date: 3 Mar 2020
Coroner: Abigail Combes
Area: South Yorkshire (West)
Responses identified: 0 / 1
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Call bell maintenance records are pre-populated as 'pass', creating a risk that checks are missed or failures aren't recorded, potentially endangering patients if call bells are non-functional.
Date
3 Mar 2020
56-day deadline
29 Apr 2020
Responses identified
0 of 1
Coroner's concerns
Call bell maintenance records are pre-populated as 'pass', creating a risk that checks are missed or failures aren't recorded, potentially endangering patients if call bells are non-functional.
View full coroner's concerns
a) The call bells are checked daily as part of routine maintenance however the document which records the checks is pre populated with a ‘P’ for pass. This could lead to rooms being missed in the checks or a failure to correct a ‘P’ to an ‘F’ in the event of a fail. It may be the case that in the event of another patient requiring a call bell and it not working this could make a significant difference to the outcome for that individual and for that reason the maintenance arrangements are important.
Report sections
Investigation and inquest
In September 2019 I commenced an investigation into the death of Eileen Pollard. The investigation concluded following an inquest on 28 February 2020 where the conclusion was:
• Natural Causes On 19 February 2019 Eileen Pollard died at hospital following a deterioration of her health conditions whilst resident in Buckingham Care Home, Penistone.
• Natural Causes On 19 February 2019 Eileen Pollard died at hospital following a deterioration of her health conditions whilst resident in Buckingham Care Home, Penistone.
Circumstances of the death
Overnight on 27-28 March 2019, Eileen Pollard, who was resident at Buckingham Care Home for respite care, became unwell with the symptoms of a myocardial infarction. She was taken to hospital by ambulance on 29 March 2019 where she passed away two days after her admission. During the course of her admission Eileen Pollard raised concerns about the fact that she had been pressing her nurse call bell which was not answered or was not working. The medical evidence presented at inquest was clear that even if this was the case, the outcome for Eileen Pollard would not have been any different.
Action should be taken
I request that the organisation look again at the forms and documentation used to check call bells and reconsider whether these should be pre populated or blank to be completed contemporaneously with the check.
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Report details
- Reference
- 2020-0053
- Date of report
- 3 March 2020
- Coroner
- Abigail Combes
- Coroner area
- South Yorkshire (West)
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: 29 Apr 2020.
Sent to
- Crown Care