Source · Prevention of Future Deaths

Arthur Adley

Ref: 2016-0358 Date: 13 Sep 2016 Coroner: Andrew Walker Area: London (North) Responses identified: 1 / 1 View PDF

Safeguarding systems in care homes were inadequate to prevent a resident who posed a risk to others from causing harm.

Date 13 Sep 2016

56-day deadline 23 Apr 2017 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Safeguarding systems in care homes were inadequate to prevent a resident who posed a risk to others from causing harm.

View full coroner's concerns

That the systems for safeguarding for residents who present a risk to other residents when placed in care homes did not prevent that risk to other residents.

Responses

1 respondent

Department of Health Central Government

18 Nov 2016 PDF

Noted

The Department of Health acknowledged the concerns and forwarded the report to the Care Quality Commission (CQC), the independent regulator of health and adult social care providers in England. (AI summary)

View full response

Philip Dunne MP Minister of State for Health Department of Health Richmond House 79 Whitehall London SWIA 2NS Andrew Walker Tel: 020 7210 4850 Senior Coroner Northern District of Greater London North London Coroner Court 29 Wood Street Barnet ENS 4BE 18 November 2016 Ulur Thank you for your report to Secretary of State. I responding as the Minister with responsibility for quality and regulation policy at the Department of Health: Iwas sorry to read of the very sad circumstances surrounding Mr Adley' s death, please pass my condolences to his family and loved ones: The CQC is the independent regulator of health and adult social care providers in England. I have, therefore, sent your report to the Care Quality Commission (CQC) as the body with oversight in the case. Under the Health and Social Care Act 2008 (the 2008 Act) all providers of regulated activities have to register with CQC and follow a set of fundamental standards of safety and quality below which care should never fall. The fundamental standards describe the basic requirements that providers should always meet; and outline the outcomes that services users should always expect. The CQC inspect the providers against these fundamental standards and their inspections ask every provider are safe, effective, caring, well led and responsive to people's needs. One of the fundamental standards relates to safeguarding service users from abuse and improper treatment: This regulation requires providers to establish systems and processes and operate them effectively to prevent abuse of service users and to investigate immediately if the provider becomes aware ofany allegation Or evidence of abuse. The CQC has published guidance to providers on how to meet the regulations and under 'Safeguarding service users from abuse and improper treatment In regulation am they

13,the CQC advises that providers must do all that is reasonably practical to mitigate risks. They should follow practice guidance and must adopt control measures to make sure the risk is as low as is reasonably possible. They should review methods and measures and amend them to address changing practice. The full regulation can be found on the CQC website at http:I www cqc org uklcontent-regulations-service_ providers-and-managers Thank you for bringing the circumstances of Mr Adley's death to our attention. 0sduseoro( PHILIP DUNNE RECEIVED 2 9 Nov 2016 good

Report sections

Investigation and inquest

On the 9th day of April 2016 I opened an investigation into the death of Arthur Thomas Adley , aged 92 years old. I opened an inquest on the 22nd day of April 2016. The inquest concluded on the 13th September 2016. The conclusion of the inquest was “Consequences of a fall”, the medical case of death was 1a Cardio respiratory failure, 1 (b) blunt force trauma to the head and neck and associated complications.

Circumstances of the death

On the 8th April 2016 at about 7.30 Arthur Thomas Adley, who was a resident at Candle Court Nursing Home, was pushed by another resident and caused to fall striking his face and head on a table as he fell.

The resident who had pushed Mr Adley was regularly assessed with regard to his suitability to remain at Candle Court Nursing Home.

Steps were taken to protect other residents and the resident who had pushed Mr Adley by ensuring that there were no obstacles in that resident’s way.

On this occasion the member of staff looking after Mr Adley in the lounge at the nursing home was aware that the resident who was likely to push other residents was leaving the lounge but had left Mr Adley for a moment. In that moment the resident approached Mr Adley and pushed him over.

This incident happened at 7.30 in the morning.

North London Coroners Court, 29 Wood Street, Barnet EN5 4BE

Telephone 0208 447 7680 Fax 0208 447 7689

Her Majesty’s Coroner for the Northern District of Greater London (Harrow, Brent, Barnet, Haringey and Enfield)

Mr Adley was taken to hospital where he died the same day.

There were 10 incidents over 3 years where the resident who pushed Mr Adley touched other residents in a way that may have resulted in a fall and on some occasions did result in the resident being pushed and falling causing injury.

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Report details

Reference: 2016-0358
Date of report: 13 September 2016
Coroner: Andrew Walker
Coroner area: London (North)

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 23 Apr 2017 (estimated).

Sent to

Department of Health and Social Care

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.