Source · Prevention of Future Deaths
Vincent Smith
Ref: 2016-0134
Date: 6 Apr 2016
Coroner: Derek Winter
Area: Sunderland
Responses identified: 0 / 1
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The nursing home failed to adequately assess and act upon a resident's vulnerability to falls. Concerns were raised regarding the admissions policy, falls risk assessments, and associated staff training.
Date
6 Apr 2016
56-day deadline
1 Jun 2016 est.
Responses identified
0 of 1
Coroner's concerns
The nursing home failed to adequately assess and act upon a resident's vulnerability to falls. Concerns were raised regarding the admissions policy, falls risk assessments, and associated staff training.
View full coroner's concerns
_ Whilst at the Nursing and Care Home members of staff were to monitor and suppori Mr Smith's mobilisation Although on notice after his first fall, there were insufficient steps taken to assess and act upon Mr Smith' s vulnerability Civic Centre; Burdon Road. Sunderland, SRZ 7DN Tel ([91 56/7843 Fax 0/91 5537803 DX 60729 Sunderland WWW. sunderland_ govukicoroner aged Village my Village being
Evidence suggested that there to be:
1) a review of the Home' $ formal written admissions policy to include verification of the information provided about the suitability of a prospective resident for admission; aS well as
2) a review of the Home 's formal written falls risk assessments policy and associated training for staff;, together with any other steps that ought to be taken to mitigate the risks of falls.
Evidence suggested that there to be:
1) a review of the Home' $ formal written admissions policy to include verification of the information provided about the suitability of a prospective resident for admission; aS well as
2) a review of the Home 's formal written falls risk assessments policy and associated training for staff;, together with any other steps that ought to be taken to mitigate the risks of falls.
Report sections
Investigation and inquest
On 16"h November 2015 [ commenced an investigation into the death of Mr Vincent Smith, 80 years. The investigation concluded at the end of the Inquest on ] April 2016. The conclusion of the Inquest was Accident Contributed to by Neglect:
Circumstances of the death
Mr Smith was admitted to the Nursing and Care Home Murton on 6"h November 2015_ He had unwitnessed falls on 7th and 86 November; which led to his admission to Sunderland Royal Hospital on 9u November 2015. On 15th November 2015 Mr Smith died from a head injury and bilateral pneumonia
Action should be taken
In my opinion action should be taken to prevent future deaths and [ believe you have the power to take such action:
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Report details
- Reference
- 2016-0134
- Date of report
- 6 April 2016
- Coroner
- Derek Winter
- Coroner area
- Sunderland
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: 1 Jun 2016 (estimated).
Sent to
- Village Nursing and Care Home