Source · Prevention of Future Deaths
Wycliffe Matthews
Ref: 2017-0299
Date: 18 Oct 2017
Coroner: John Pollard
Area: Manchester (West)
Responses identified: 0 / 1
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Care home staff lacked adequate training on hoist use and failed to maintain proper records of critical events.
Date
18 Oct 2017
56-day deadline
22 Jan 2018 est.
Responses identified
0 of 1
Coroner's concerns
Care home staff lacked adequate training on hoist use and failed to maintain proper records of critical events.
View full coroner's concerns
During the Inquest evidence was heard that:- The staff at the home seemed untrained or at least inadequately trained on the use of the hoist: ii The staff failed to keep any, or any proper, note of the events which led to the death: 11t times
Report sections
Circumstances of the death
On the of December 2016 in Alexander Grange Care Home, he was hoisted three in standing hoist: On the first and second occasions he had difficulties and on the third occasion he let go of the hoist ad sat back in the chair causing traumatic spinal cord injuries: This led to his death and pneumonia.
Action should be taken
In my opinion urgent action should be taken to prevent future deaths and believe that you have the power to take such action:
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Report details
- Reference
- 2017-0299
- Date of report
- 18 October 2017
- Coroner
- John Pollard
- Coroner area
- Manchester (West)
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: 22 Jan 2018 (estimated).
Sent to
- Grange Care Home