Source · Prevention of Future Deaths

Sheila Ross

Ref: 2018-0081 Date: 19 Mar 2018 Coroner: Derek Winter Area: Sunderland Responses identified: 0 / 1 View PDF

The care home used an outdated falls risk assessment, had a limited buzzer system unable to provide timely assistance, and exhibited poor communication with the family.

Date 19 Mar 2018

56-day deadline 11 Aug 2018 est.

Responses identified 0 of 1

Care Home Health related deaths

Coroner's concerns

AI summary

The care home used an outdated falls risk assessment, had a limited buzzer system unable to provide timely assistance, and exhibited poor communication with the family.

View full coroner's concerns

In the circumstances Civic Centre; Burdon Road,Sunderland, SR2 7DN Tel 0191 5617843 Fax 0191 5537803 DX 60729 Sunderland WWW.sunderland.gov uklcoroner aged sepsis urinary it is statutory duty to report to you: (1) The falls risk assessment tool used by the Care Home staff appeared to be outdated, and the subsequent level of falls risk recorded by staff was not in keeping with the score generated by the assessment tool.

(2) The Care Home buzzer system only allowed one alert mechanism personal buzzer or sensor mat to be active at any one time, unless a resident could access the wall buzzer_ This can leave residents unable to summon timely assistance when needed: (3) There was poor communication from the Care Home with Sheila' s family members, which led them to lose confidence in the standard of care Sheila was receiving:

Report sections

Investigation and inquest

On 12th November 2017 Mrs Sheila Sullivan Ross (Sheila), 86 years, died at Sunderland Royal Hospital. The Inquest; as part of my Investigation, concluded on 14uh March 2018, when [ recorded a conclusion of Accident. The Cause of Death following Post-Mortem Examination was: Ia Pelvic Haematoma Ib Fracture Pubic Rami II Chronic Ischaemic Heart Disease

Circumstances of the death

Sheila was admitted to Sunderland Royal Hospital on 10th November 2017 following an unwitnessed fall at the Hylton View Care Home_ It was initially thought that Sheila had not sustained any serious injury from her fall. However; after care staff had hoisted her into her chair, she began to complain of pain, and an ambulance was called. An X-ray examination showed stable bilateral pubic rami fractures, which were suitable for supportive treatment only via rest and analgesia: Sheila was found to have a urinary tract infection and was treated for urinary via insertion of catheter; intravenous fluids, oxygen and antibiotics. pelvic ultrasound scan was ordered to assess her bladder issue. Sheila sadly deteriorated and passed away on 12th November 2017.

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:

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Report details

Reference: 2018-0081
Date of report: 19 March 2018
Coroner: Derek Winter
Coroner area: Sunderland

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: 11 Aug 2018 (estimated).

Sent to

Hylton View Care Home

Part of a series

2 reports

2017-0384 0 responses identified

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.