Source · Prevention of Future Deaths
Margaret Richardson
Ref: 2016-wp25380
Date: 19 Aug 2016
Coroner: Caroline Beasley-Murray
Area: Essex
Responses identified: 0 / 1
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A robust, comprehensive Action Plan with timescales needs to be put in place, following the findings of the Serious Incident Investigation and the evidence heard during the inquest.
Date
19 Aug 2016
56-day deadline
16 Oct 2016
Responses identified
0 of 1
Coroner's concerns
A robust, comprehensive Action Plan with timescales needs to be put in place, following the findings of the Serious Incident Investigation and the evidence heard during the inquest.
View full coroner's concerns
it is my statutory duty to report to you.
(1) a robust, comprehensive Action Plan with timescales' needs to be put in place, following the findings of the Serious Incident Investigation and the evidence heard during the inquest.
(1) a robust, comprehensive Action Plan with timescales' needs to be put in place, following the findings of the Serious Incident Investigation and the evidence heard during the inquest.
Report sections
Investigation and inquest
On [26 January 2016] I commenced an investigation into the death of Margaret Ann Richardson. The investigation concluded at the end of the inquest on 17 August 2016.
The conclusion of the inquest was a Narrative conclusion:- On 5 September 2015, the deceased was admitted to Kitwood ward St Margaret's Hospital Epping. She suffered a number of falls and she died on 25 January 2016 in Princess Alexandra Hospital Harlow. At least the last fall may have contributed to her death. There were failings in the implementation of the North Essex Mental Health Partnership Trust's Prevention and Management of Falls Policy in Kitwood ward.
The cause of death was 1a) Bilateral pneumonia 11) subdural haematomata, ischaemic heart disease
The conclusion of the inquest was a Narrative conclusion:- On 5 September 2015, the deceased was admitted to Kitwood ward St Margaret's Hospital Epping. She suffered a number of falls and she died on 25 January 2016 in Princess Alexandra Hospital Harlow. At least the last fall may have contributed to her death. There were failings in the implementation of the North Essex Mental Health Partnership Trust's Prevention and Management of Falls Policy in Kitwood ward.
The cause of death was 1a) Bilateral pneumonia 11) subdural haematomata, ischaemic heart disease
Circumstances of the death
The deceased suffered at least 5 falls while a patient in Kitwood Ward St Margaret's Hospital Epping and she died in Princess Alexandra Hospital Harlow after the last fall.
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Report details
- Reference
- 2016-wp25380
- Date of report
- 19 August 2016
- Coroner
- Caroline Beasley-Murray
- Coroner area
- Essex
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: 16 Oct 2016.
Sent to
- North Essex Mental Health Partnership Trust