Source · Prevention of Future Deaths

Keith Whetton

Ref: 2019-0452 Date: 24 Dec 2019 Coroner: Andrew Haigh Area: Staffordshire (South) Responses identified: 1 / 1 View PDF

The care home failed to seek prompt medical attention after a resident's fall and did not inform family members in a timely manner.

Date 24 Dec 2019

56-day deadline 18 Feb 2020 est.

Responses identified 1 of 1

Care Home Health related deaths

Coroner's concerns

AI summary

The care home failed to seek prompt medical attention after a resident's fall and did not inform family members in a timely manner.

View full coroner's concerns

5. _ You should already be aware of the concerns in this matter. Even if medical attention was not sought for Keith on 7th September it clearly should have been requested on 8th September: We hope that this has now been taken on board by your home: Additionally, family members felt that should have been informed earlier about Keith's fall and wonder if lessons have been learned here as well:

Responses

1 respondent

Hunters Lodge Care Centre Other

27 Jan 2020 PDF

Action Taken

Following a review of the coroner's report, staff have been supervised and completed falls training. The falls policy has been updated, and staffing levels have been increased to improve observation and patient safety. (AI summary)

View full response

Dear Andrew Haigh am writing to vou in response of the letter vou sent to myself regarding Keith Graham Whetton (deceased)_ After reviewing the coroners report we have been through your concerns and we have already addressed the concerns that you have highlighted, to to prevent future deaths: Following the fall all staff have been supervised on the matter and have completed falls training: Trained staff are going to be commenced additional training via remit training group. | myself and the clinical lead have completed the course and believe it will be beneficial for other senior to complete_ have also reviewed the policy and procedure of falls within the home and spoken with the regional mangers regarding unwitnessed falls and the policy and procedure has now been updated and in place within the home: The policy is now more robust and has clear instructions on steps to be taken in the event of a fall: After my trend analysis and internal investigation have increased staffing levels to increase observation of residents and further support to the nursing team: This level of support has had a positive impact in reducing falls and improving patient safety: believe that actions taken have improved the service, especially around patient safety: feel we have all learned lessons regarding this matter and as a service we will continue to strive to improve the care we deliver to our clients and families. Ifthere is any further information you require please do not hesitate to ask:

Report sections

Investigation and inquest

On 23 October 2019 | commenced an investigation into the death of Keith Graham WHETTON: The investigation concluded at the end of the inquest: The conclusion of the inquest was An elderly man in declining health who fell in a care home: The cause of death was: 1a End Stage Dementia and frailty Fracture right neck of femur 3 . CIRCUMSTANCES OF THE DEATH Keith had an unwitnessed fall in his room at Hunters Lodge Care Facility on the 07.09.191 attended as part of his Monday morning visit to the care home on the 09.09.19. He then sent Keith to New Cross Hospital Wolverhampton on the 09.09.19, where he was found to have a fractured right hip. He was then operated on and had a hemiarthroplasty and remained in hospital, until he was discharged back to the Care home on the 27.09.19. Sadly he continued to deteriorate and died at the home on the 05.10.19 Staffordshire Place, Stafford, ST16 2LP Telephone: 01785 276126 or 276127 Email; sscor@staffordshire.gov.Uk Lodge

4CQRONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken: In the circumstances it is my statutory duty to report to you:
5. The MATTERS OF CONCERN are as follows_ You should already be aware of the concerns in this matter. Even if medical attention was not sought for Keith on 7th September it clearly should have been requested on 8th September: We hope that this has now been taken on board by your home: Additionally, family members felt that should have been informed earlier about Keith's fall and wonder if lessons have been learned here as well:

Action should be taken

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

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2019-0452
Date of report: 24 December 2019
Coroner: Andrew Haigh
Coroner area: Staffordshire (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: 18 Feb 2020 (estimated).

Sent to

Hunters Lodge Care Home

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

Contains public sector information licensed under the Open Government Licence v3.0.