Source · Prevention of Future Deaths

Helen Cannon

Ref: 2017-0260 Date: 16 Aug 2017 Coroner: Jennifer Leeming Area: Manchester (City) Responses identified: 1 / 5 View PDF

Emergency responders failed to seek medical assistance for a patient with internal hemorrhage after a fall, misinterpreting her symptoms. A subsequent flawed investigation failed to identify critical inaccuracies in risk assessment completion and staff understanding.

Date 16 Aug 2017

56-day deadline 3 Jan 2018 est.

Responses identified 1 of 5

Community health care and emergency services related deaths

Coroner's concerns

AI summary

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1. The emergency responders did not seek medical or paramedic assistance for Mrs Cannon because she was complaining of suffering aching rather than pain. It transpired that Mrs Cannon had suffered internal haemorrhage as a result of a pelvic fracture sustained in her fall, and this led to her death two days later. Evidence was heard at the Inquest from a Consultant Trauma and Orthopaedic Surgeon that in the circumstances it would have been good practice to have obtained medical or paramedic assistance for Mrs Cannon.

2. Following Mrs Cannon’s death Eldercare carried out an investigation. The investigation was flawed in that it did not address clear inaccuracies in the Moving and Handling Risk assessment checklist completed by one of the Emergency Responders, nor did it discover that the other Emergency Responder attending did not understand that he was agreeing with the accuracy of the information recorded on the checklist when he countersigned it. It was his belief that he signed the checklist simply to agree that he had been present.

Responses

1 respondent

Response

PDF

Noted

Illegible response. (AI summary)

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Report sections

Investigation and inquest

On the 7th day of April 2017 I commenced an investigation into the death of Helen Theresa Cannon, 87 years, born the 8th July 1930. The investigation concluded at the end of the Inquest on the 3rd of August 2017.

The medical cause of death was:-

Ia Myocardial Infarction Ib Haemorrhage Associated with Pelvic Fracture II Cardiac Failure

The conclusion of the Inquest was Accidental Death.

Circumstances of the death

On the 2nd of April 2017 Helen Theresa Cannon fell at her home address,

Wigan. She was a client of Eldercare, which provides a national monitoring and response service. Emergency responders from that service attended to assist in getting Mrs Cannon up from the floor, which they did using a lifting cushion, as Mrs Cannon was otherwise unable to get up.

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Report details

Reference: 2017-0260
Date of report: 16 August 2017
Coroner: Jennifer Leeming
Coroner area: Manchester (City)

Responses identified

Responses identified 1 of 5

4 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 3 Jan 2018 (estimated).

Sent to

Care Quality Commission

Department for Community and Local Government

Department of Health and Social Care

Eldercare

Wigan Council

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.