Source · Prevention of Future Deaths
Freda Cordy
Ref: 2016-0190
Date: 17 May 2016
Coroner: Hassan Shah
Area: Northamptonshire
Responses identified: 0 / 2
View PDF
A patient requiring constant supervision was placed in a care home only offering 2-hourly checks, with no specific falls risk assessment despite a history of falls, and inadequate preventative equipment.
Date
17 May 2016
56-day deadline
12 Jul 2016 est.
Responses identified
0 of 2
Coroner's concerns
A patient requiring constant supervision was placed in a care home only offering 2-hourly checks, with no specific falls risk assessment despite a history of falls, and inadequate preventative equipment.
View full coroner's concerns
1) Despite the medical team identifying a need for constant supervision, the multi disciplinary team placed Mrs Cordy in Templemore Care Home which was only able to provide 2 hourly checks.
2) Despite the previous history of falls and admission to hospital on 5*^ August 2015 being precisely due to a fall, no specific falls risk assessment was undertaken either before or upon Mrs Cordy's placement in the care home.
3) Although the provision of equipment was considered on 7*'' October 2015, this resulted only in the placing of a mattress on the floor and no other preventative equipment was considered.
2) Despite the previous history of falls and admission to hospital on 5*^ August 2015 being precisely due to a fall, no specific falls risk assessment was undertaken either before or upon Mrs Cordy's placement in the care home.
3) Although the provision of equipment was considered on 7*'' October 2015, this resulted only in the placing of a mattress on the floor and no other preventative equipment was considered.
Report sections
Investigation and inquest
Mrs Freda Cordy died on the 1®' November 2015. An investigation was opened on 11* November and was concluded by way of an inquest on 13th April 2016. The medical cause of death was: la) Subdural haematoma b) Head injury 2 Hypertension, Ischaemic heart disease, dementia. A conclusion of accidental death was returned.
Circumstances of the death
Mrs Cordy was a 93 year old frail lady with multiple diagnoses including dementia. On the s"' August 2015 Mrs Cordy was admitted to the Emergency Assessment Unit at Northampton General Hospital following a fall at her home address. Mrs Cordy had a history of previous falls. The medical team identified a need for constant supervision. A multiple disciplinary meeting including Social Services and the health partnership team decided that Mrs Cordy should be placed into Templemore Care Home. On 1®' October 2015 Mrs Cordy was admitted to the care home, requiring full support for all personal care tasks. Despite the need for constant supervision that had been identified, the care home was only able to offer 2 hourly checks. No specific falls risk assessment was undertaken. Mrs Cordy fell from her bed at the care home on 2"'' October 2015 suffering an extensive subdural haematoma. After a short stay in hospital, Mrs Cordy returned to Templemore Care Home on 7^^ October 2015 at which time a falls risk assessment was undertaken resulting in a mattress being placed beside her bed. On 15th October 2015 Mrs Cordy suffered a further fall from her bed at the care home suffering bleeding from her head. Mrs Cordy was then readmitted to Northampton General Hospital where she passed away at 7.13am on 1®* November 2015 as a result of the injuries sustained in the falls.
Similar PFD reports
Related inquiry recommendations
Muckamore Abbey Inquiry
Risk-based inspection prediction
Vale of Leven Inquiry
Pressure damage risk assessment
Southport Inquiry
Shared multi-agency risk-assessment tool
Southport Inquiry
LCC online harms risk assessment review
Post Office Horizon Inquiry
Amend GLOS to allow claimants oral submissions at panel hearings
Post Office Horizon Inquiry
Post Office to engage in negotiations during HSSA appeal period
Muckamore Abbey Inquiry
Whole-system commissioning with cross-agency risk assessment
Muckamore Abbey Inquiry
Inpatient facilities on risk register
Muckamore Abbey Inquiry
Cumulative risk assessment across protection plans
Muckamore Abbey Inquiry
Needs-based staffing with acuity measures
Report details
- Reference
- 2016-0190
- Date of report
- 17 May 2016
- Coroner
- Hassan Shah
- Coroner area
- Northamptonshire
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: 12 Jul 2016 (estimated).
Sent to
- Northampton General Hospital
- Templemore Care Home