Source · Prevention of Future Deaths

Robert Lowe

Ref: 2019-0319 Date: 20 Sep 2019 Coroner: Jeremy Chipperfield Area: Durham and Darlington Responses identified: 0 / 1 View PDF

Ineffective placement of pressure mats allowed residents to bypass them, and unreliable audible alarms meant falls went undetected by staff.

Date 20 Sep 2019
56-day deadline 7 Nov 2019
Responses identified 0 of 1
Care Home Health related deaths

Coroner's concerns

AI summary
Ineffective placement of pressure mats allowed residents to bypass them, and unreliable audible alarms meant falls went undetected by staff.
View full coroner's concerns
A) Circumstances at Chilton Care Centre are such that the placing of pressure mats (intended to detect residents leaving their beds unaided) is such that residents may bypass those mats; B) The use and operation of audible signals is such that important audible alarms may not come to the attention of staff. Mr LOWE left his bed and fell unwitnessed and then lay undetected by his bed for up to two hours until a scheduled welfare check. The pressure mat may not have been triggered. The basis for my concern is as follows: (A) , Chilton Home Manager said that when she investigated this matter (by which time the mat had been removed) “…there could have been a possibility that Mr LOWE, may have bypassed the mat when getting out at the top of his bed…”(witness statement dated 11th August 2019); and (B) In the same statement, stated: “Then… when staff carried out another welfare check, they found Mr Lowe on the floor. Three out of 4 staff on duty and only one believes that the mat had not activated and the other 3 could not remember if the sensor mat was making a sound or not, as the emergency buzzer was pressed and other buzzers around the home were also going at the same time, and their priority was Mr Lowe…”

Report sections

Investigation and inquest
On Sixteenth May 2019 I commenced an investigation into the death of Robert Edward LOWE aged 95. The investigation concluded at the end of the inquest on twelfth September 2019. The conclusion of the inquest was: I a Subdural Haemorrhage I b I c II Dementia, Hypertension
Circumstances of the death
Between 0159 and 0400hrs on 13th May 2019, the deceased suffered an unwitnessed fall to the floor of his bedroom at Chiltern Care Centre.
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 07 November 2019. 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 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. Jeremy CHIPPERFIELD Senior Coroner for County Durham and Darlington Dated: 20 September 2019

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Report details

Reference
2019-0319
Date of report
20 September 2019
Coroner
Jeremy Chipperfield
Coroner area
Durham and Darlington

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: 7 Nov 2019.

Sent to

Chilton Care Centre

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