Source · Prevention of Future Deaths
Doris McCarthy
Ref: 2018-0222
Date: 9 Jul 2018
Coroner: Jacqueline Devonish
Area: London (South)
56-day deadline: 3 Sep 2018 (stated in the report)
Responses identified: 0 of 2
0 responses identified · 2 indexed addressees
Judiciary.uk page ↗ Report PDF ↗
AI-generated concerns summaryThe coroner noted concerns regarding potential ongoing sensor system outages, which could prevent staff from being alerted to resident falls, and raised the need for steps to safeguard residents known to slide when seated in a chair.
Care Home Health related deaths
Coroner's concerns AI summary
The coroner noted concerns regarding potential ongoing sensor system outages, which could prevent staff from being alerted to resident falls, and raised the need for steps to safeguard residents known to slide when seated in a chair.
View full coroner's concerns
(1) The sensor system outages might still exist, leaving residents vulnerable due to staff not being alerted to a fall (2) Steps taken to safeguard residents who are known to slide when placed to sit in a chair.
Report sections
Investigation and inquest
On 2 November 2017 I commenced an investigation into the death of Doris McCarthy, aged 92 years. The investigation concluded at the end of the inquest on 6 July 2018. The conclusion of the inquest was that Doris McCarthy died from natural causes as a result of a pulmonary embolism, with an underlying subdural haemorrhage caused by recurrent falls.
Circumstances of the death
Mrs McCarthy became a resident of Baycroft Orpington on 19 September 2017 due to her reducing mobility, declining memory, recurrent falls and inability to take care of her personal needs in her own home. She had been placed as a resident directly following an inpatient stay in hospital, during which time she was identified as having a subdural haematoma, and at high risk of falls.
The General Manager, during the period of residence, gave evidence at inquest that Baycroft is a state of the art facility with sensors and alarms alerting staff of resident movements. This included a call bell system activated by sensors both in beds and chairs, and falls wrist watches.
The General Manager identified two ‘fall’ incidents whilst in the home on 20 and 28 September 2017. On both occasions Mrs McCarthy slid from her chair but the sensor system did not alert staff. The evidence given was that the system had frequent outages, and that it was not possible know when such an outage had occurred.
The General Manager, during the period of residence, gave evidence at inquest that Baycroft is a state of the art facility with sensors and alarms alerting staff of resident movements. This included a call bell system activated by sensors both in beds and chairs, and falls wrist watches.
The General Manager identified two ‘fall’ incidents whilst in the home on 20 and 28 September 2017. On both occasions Mrs McCarthy slid from her chair but the sensor system did not alert staff. The evidence given was that the system had frequent outages, and that it was not possible know when such an outage had occurred.
Similar PFD reports Shared signals
Responses identified
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 3 Sep 2018 (stated in the report).
Sent to
- Baycroft Care Homes
- Senior Villages
Source links
Data: judiciary.uk.