Source · Prevention of Future Deaths
Beryl Goode
Ref: 2017-0246
Date: 29 Aug 2017
Coroner: Ian Pears
Area: Bedfordshire and Luton
Responses identified: 0 / 1
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Care home night staff, lacking medical training, failed to consider a head injury as the cause of a resident's confusion after a fall, indicating a need for improved awareness and assessment training.
Date
29 Aug 2017
56-day deadline
26 Nov 2017 est.
Responses identified
0 of 1
Coroner's concerns
Care home night staff, lacking medical training, failed to consider a head injury as the cause of a resident's confusion after a fall, indicating a need for improved awareness and assessment training.
View full coroner's concerns
(1) At no point did the night shift staff consider that a head injury could have been the cause of the deceased's confusion.
(2) It is accepted that the night shift are not medically trained. However, that makes it all the more important that they are aware of the possibility of a head injury to the residents, even in circumstances where the resident denies an injury: (3) It is also accepted that the deceased may not actually have had a head injury from the first fall, Nevertheless, without training, the staff were not able to exclude a head injury: (4) It is also accepted that calling the emergency services some 2 hours earlier would not prevented her death if she had sustained a head injury in the first fall However in certain scenarios, residents in the future may have their lives saved if head injury is considered as possible diagnosis.
(2) It is accepted that the night shift are not medically trained. However, that makes it all the more important that they are aware of the possibility of a head injury to the residents, even in circumstances where the resident denies an injury: (3) It is also accepted that the deceased may not actually have had a head injury from the first fall, Nevertheless, without training, the staff were not able to exclude a head injury: (4) It is also accepted that calling the emergency services some 2 hours earlier would not prevented her death if she had sustained a head injury in the first fall However in certain scenarios, residents in the future may have their lives saved if head injury is considered as possible diagnosis.
Report sections
Investigation and inquest
On 3rd May 2017 commenced an Investigation into the death of
Circumstances of the death
On the night of the 30th April 2017 the deceased fell whilst trying to use the commode_ She denied any injury; was checked and put on appropriate observations_ At around 01.00 hours she was found confused in the corridor having visited another resident's room_ The staff this down to urinary tract infection and did not consider the possibility of a head injury. She was then found on the floor of the corridor at 03.25 hours_ As a result of the Senior Coroner; The Court House; Woburn Street; AMPTHILL, Bedfordshire, MK4S ZHX Tel 0300-300-6559 Fax 0300-300-8267 very put obvious head injury, the emergency services were called and she was taken to Bedford Hospital where she died on 2nd 2017 .
Action should be taken
In my opinion action should be taken to prevent future deaths and believe Abbotsbury Elderly Persons Home have the power to take such action:
Copies sent to
law). have also sent it to the Care Quality Commission
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Report details
- Reference
- 2017-0246
- Date of report
- 29 August 2017
- Coroner
- Ian Pears
- Coroner area
- Bedfordshire and Luton
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: 26 Nov 2017 (estimated).
Sent to
- Abbotsbury Elderly Persons Home