Source · Prevention of Future Deaths
John Smith
Ref: 2016-0366
Date: 18 Oct 2016
Coroner: Jean Harkin
Area: Manchester (City)
Responses identified: 0 / 2
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Inadequate discharge risk assessment failed to consider a mobility-impaired, incontinent dementia patient's specific home environment and care needs, contributing to a fall and subsequent death.
Date
18 Oct 2016
56-day deadline
13 Dec 2016
Responses identified
0 of 2
Coroner's concerns
Inadequate discharge risk assessment failed to consider a mobility-impaired, incontinent dementia patient's specific home environment and care needs, contributing to a fall and subsequent death.
View full coroner's concerns
Inadequate risk assessment prior t0 discharge evidence heard in court confirmed that the assessment was done using 3 standard stepslstairs. There was no consideration of toilet needs requiring urgent toileting and Mr Smith having to climb a difficult staircase in a Further; there were professional and family concerns raised regarding discharge
2. Inadequate questioning for assessment and discharge purpose Consultant Orthopaedic Surgeon, agreed in court that he would not have discharged Mr Smith knowing the above_ As a result of the discharge of a mobility and incontinent comprised patient; also suffering with dementia and caring for his wife who also had dementia (in respite care prior to Mr Smith'$ discharge) Mr Smith suffered a further fall at home which lead to his death indirectly:
2. Inadequate questioning for assessment and discharge purpose Consultant Orthopaedic Surgeon, agreed in court that he would not have discharged Mr Smith knowing the above_ As a result of the discharge of a mobility and incontinent comprised patient; also suffering with dementia and caring for his wife who also had dementia (in respite care prior to Mr Smith'$ discharge) Mr Smith suffered a further fall at home which lead to his death indirectly:
Report sections
Circumstances of the death
Mr Smith had been admitted to Wythenshawe Hospital Manchester on 13th September 2015 following a fall in his garden. He looked after his wife who had dementia and he himself had been diagnosed with dementia Despite concerns from paramedics (who made a safeguarding referral) , his family and (CPN) , who advised an intermediate care assessment; he was discharged home_ It was clear t0 all that Mr Smith had incontinence problems and had to walk upstairs to the bathroom: He was unsteady on his feet and the stairs at were difficult to navigate. He also struggled to iook after himself: He was discharged home on 22nd September 2015. Mr Smith was re-admitted to Wythenshawe Hospital on 24th September 2015 following fall at his home address. He underwent surgery t0 repair a fractured neck of femur on 26'h September 2015 and post surgery he developed aspiration pneumonia and died at 23.59 hours on 1 October 2015. City May home
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action.
Copies sent to
[DATE] [SIGNED BY CORONER] 18 October 2016 hurry
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Report details
- Reference
- 2016-0366
- Date of report
- 18 October 2016
- Coroner
- Jean Harkin
- Coroner area
- Manchester (City)
Responses identified
Responses identified
0 of 2
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 13 Dec 2016.
Sent to
- Lord Chancellor
- Wythenshawe Hospital