Source · Prevention of Future Deaths

Frederick Bevan

Ref: 2017-0060 Date: 9 Mar 2017 Coroner: Emma Brown Area: Birmingham and Solihull Responses identified: 0 / 1 View PDF

A poor handover practice led to paramedics receiving an inaccurate incident history from a non-witnessing nurse instead of the witnessing carer, risking detrimental effects on treatment.

Date 9 Mar 2017

56-day deadline 4 May 2017 est.

Responses identified 0 of 1

Care Home Health related deaths

Coroner's concerns

AI summary

A poor handover practice led to paramedics receiving an inaccurate incident history from a non-witnessing nurse instead of the witnessing carer, risking detrimental effects on treatment.

View full coroner's concerns

was satisfied that Mr. Bevan'$ fall was witnessed by a carer] However, two paramedics who attended in response to the 999 call following the fall both gained the clear understanding that the fall was not witnessed; described that there were 4 or 5 members of staff present and the scene appears to have been somewhat chaotic The likely explanation for the paramedics misunderstanding is that a clear hand-over of the history of the incident was not provided by the witness_ but rather the nurses who has responded to the emergency call 'took over' . This was accepted as a potential explanation by the home manager Judy Williams, who informed me that the policy is that the lead nurse should give the incident history to the paramedics: my concern is that if the history is not provided by the witness (regardless of whether they are a carer or a nurse} there is a risk that the correct history will not be given to emergency services which in some cases could have a detrimental effect on treatment: and they

Report sections

Investigation and inquest

On 07/10/2016 commenced an investigation into the death of Frederick Bevan: The investigation concluded at the end of an inquest on Ist March 2017. The conclusion of the inquest was Accidental Death;

Circumstances of the death

Mr Bevan passed away on 4/10/16 at Bromford Lane Care Centre, 28 Fairholme Lane; Washwood Heath, Birmingham a5 a result ofa head injury following a fall at the home on 22/9/16. Mr Bevan had been a resident of the Home since June 2014 and was subject to a Deprivation of Liberty Safeguarding Order due to his dementia: His health had deteriorated in the summer of 2016 with a number of falls recorded by the Home; On 22/9/16 he suffered another fall which was witnessed by a staff member at the Home: Paramedics attended the Home promptly Mr Bevan was admitted to Heartlands Hospital quickly. Following medical assessments it was concluded that no treatment or procedure would be beneficial to him. The decision was taken to return Mr Bevan to Bromford Lane to ensure his remaining days were as comfortable as possible He passed away shortly afterwards at the Home: Based on information from the Deceased's treating clinicians the medical cause of death was determined to be: 1(a) SUBARACHNOID HAEMORRHAGE 1(b) FALL 1(c) DEMENTIA

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: 2017-0060
Date of report: 9 March 2017
Coroner: Emma Brown
Coroner area: Birmingham and Solihull

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: 4 May 2017 (estimated).

Sent to

Bondcare Limited

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.