Source · Prevention of Future Deaths
Olive Wilmott
Ref: 2016-0231
Date: 21 Jun 2016
Coroner: Stephanie Haskey
Area: Nottingham
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner noted a lack of effective investigation or safeguarding referral regarding possible pushing, despite medical records, and insufficient evidence of mandated 15-minute observations. There were also insufficient night staff to meet residents' needs on the dementia unit.
Date
21 Jun 2016
56-day deadline
16 Aug 2016
stated in the report
Responses identified
0 of 1
Coroner's concerns
The coroner noted a lack of effective investigation or safeguarding referral regarding possible pushing, despite medical records, and insufficient evidence of mandated 15-minute observations. There were also insufficient night staff to meet residents' needs on the dementia unit.
View full coroner's concerns
_ That there were references in the medical records to Miss Wilmott possibly having been pushed, but no or no effective investigation of circumstances was made at the time and no Safeguarding referral was made. That Miss Wilmott was assessed as requiring observation at 15 minute intervals, but there was no evidence that this had been in place and at the time of the event there were insufficient staff in place for her and other residents' needs (one staff member dedicated per floor of the dementia unit during the night shift) .
Report sections
Investigation and inquest
On 21st March 2016 an investigation was begun into the death of Olive Wilmott; who died on 30th December 2015. The investigation concluded at the end of the Inquest on 20"h June 2016. The conclusion of the Inquest was that Olive Wilmott died as a result of the effects of a urine infection and severe Dementia, with a hip fracture which she suffered at Coppice Lodge Residential Care Home on 6th December 2015 contributory factor, and a Narrative Conclusion was recorded_
Circumstances of the death
Miss Wilmott was found on the floor of a communal area of the Home, having fractured her hip. The exact cause of this event remains unknown:
Action should be taken
In my opinion action should be taken to prevent future deaths and believe your organisation has the_power to take such action: being the
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Report details
- Reference
- 2016-0231
- Date of report
- 21 June 2016
- Coroner
- Stephanie Haskey
- Coroner area
- Nottingham
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 Aug 2016 (stated in the report).
Sent to
- Ideal Care Home Ltd