Source · Prevention of Future Deaths

Joseph Lafferty

Ref: 2019-0275 Date: 7 Aug 2019 Coroner: Chris Morris Area: Manchester (South) Responses identified: 0 / 2 View PDF

CQC inspections fail to consistently include external premises areas routinely used by residents, risking overlooked safety issues outside the immediate care environment.

Date 7 Aug 2019
56-day deadline 13 Dec 2019 est.
Responses identified 0 of 2
Care Home Health related deaths

Coroner's concerns

AI summary
CQC inspections fail to consistently include external premises areas routinely used by residents, risking overlooked safety issues outside the immediate care environment.
View full coroner's concerns
_ Over the course of the inquest, evidence was heard to the effect that The Cedars Rest Home had been inspected by the Care Quality Commission in 2016 and assessed as 'Good' . Following Mr Lafferty' s death, a further inspection took place and a of 'Requires Improvement' was arrived at, It is a matter of concern that, according to the evidence of the Care Quality Commission Inspector who gave evidence at court, there is no requirement on inspectors to include external aspects of a registered premises in the course of a CQC inspection in every case_ Consideration should be given to such areas automatically forming part and parcel ofa CQC inspection where these are routinely in use by residents in course of the provision of regulated activities.

Report sections

Investigation and inquest
On 25th October 2018, Christopher Murray, Assistant Coroner, opened an inquest into the death of Joseph Kevin Lafferty who died on 24th June 2018at Wythenshawe Hospital, Manchester, at the age of 85 years The investigation concluded with an inquest which heard between 1" _ 4th July 2019 and which concluded with a Narrative conclusion to the effect that Mr Lafferty died as a consequence of a fall at his care home which occurred after he left the building and gained access to an area of grounds to which it was not intended he should have access, whilst unsupervised.
Circumstances of the death
Mr Lafferty was formally diagnosed with dementia in 2014. Over subsequent vears, problems with his short term memory increased and his mobility declined. In January 2018, Mr Lafferty was admitted to hospital following a fall, and treated for an infection It was appreciated that Mr Lafferty' $ condition was nOw such that he could not safely return home Following assessments undertaken in hospital, it was identified Mr Lafferty required 24 hour EMI residential care. As such, on 1" May 2018, Mr Lafferty moved into The Cedars Rest Home, Bowden, Altrincham: Whilst at The Cedars, Mr Lafferty was noted to be wandersome. At around teatime on 11th June 2018,staff at the home realised Mr Lafferty was missing: A search ensued, and he was found outside of the care home in an area it was not intended he should have access to with serious injuries: An ambulance was called at 17:41 and arrived on scene approximately two hours later: Mr Lafferty was taken to Wythenshawe Hospital where he subsequently died. A post mortem examination concluded Mr Lafferty died a5 a consequence of:
1) A) Bronchopneumonia with congestive cardiac failure; due to
1) B) Thoracic trauma on the background of ischaemic heart disease and dementia. the
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action:
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Dated: 7th August 2019 Signature: Chris Morris Hi Area Coroner, Manchester South

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Report details

Reference
2019-0275
Date of report
7 August 2019
Coroner
Chris Morris
Coroner area
Manchester (South)

Responses identified

Responses identified 0 of 2
2 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 13 Dec 2019 (estimated).

Sent to

Care Quality Commission
NHS England

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