Elsie Raper

On 3r September 2015 commenced an investigation into the death of Elsie Raper; The investigation concluded at the end of the inquest on 18 March 2016. The conclusion of the inquest was that Elsie Raper died from Ia. Multiple Bone Fractures (of left tibia, left fibula and Ieft femur) treated 1b. Multiple Falls including recent fall on 218 August 2015, Frailty of Old Age and Osteoporosis_ She suffered a fall on 10lh June 2015, resulting in a fractured tip of femur for which she was treated: The implications of osteoporosis were not appreciated: She suffered further falls when she was admitted to Darlington Memorial Hospital on 11 just 2015 and on 215 August 2015 when she suffered fractures of the left tibia and fibula which could have been; but were not diagnosed until 25th August 2015. She died at Grosvenor Park Care Home, Darlington on 26ih August 2015. The overall conclusion was accidental falls causing_ fractures

Elsie Raper was born on 6lh August 1921. She entered the Grosvenor House Care Home; Burnside Road, Darlington in January 2014. She had a diagnosis of osteoporosis from 2007 was self-mobilising: She had capacity. She suffered a fall on 10h June 2015. This resulted in a fractured tip of femur: She was treated for this. Osteoporosis is mentioned in her medical notes from the GP's surgery, Neasham Road, at this time. She was admitted to hospital and discharged back to Grosvenor House Care Home on 22md June 2015. She had a further fall on 11"h August; There was another fall on 21s' August; In her evidence the Care Manager accepted that there was insufficient attention given to the possibility of fractures arising in the light of Elsie's osteoporosis. Elsie received on most days attention including examination on 13"" August; 15" August, August, August and August 2015 from nurses from Darlington Out of Hours Service and Darlington District Nursing: She was examined by a GP from Neasham Road Surgery on 17lh August 2015 and 24th August 2015. She was examined by a Doctor from Bishop Auckland Urgent Care on 23r August 2015.It was on 24h August that she was referred to hospital. She was referred for X-Ray: It was the evidence of her daughter of Elsie Raper that it was she who insisted upon the X-Ray: The evidence of a GP from Neasham Road Surgery was that he accepted that there had been a delay in treating the fractures: The evidence from a Consultant in Emergency Medicine at Darlington Memorial Hospital was that the presentation of Elsie's leg on 25" August,_irrespective of the X-Ray results,made tor a likely diagnosis of fractures to the Auge She Home 17th 22n _ 24th

Elsie s family members stated that she had been in extensive pain after 21" August

In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power t0 take such action: YOuR RESPONSE are under a to respond to this report within 56 days of the date of this report, namely by April 2016_ 1, the Coroner, may extend the period: Your response must contain details of action taken or proposed to be taken, setting out the timetable for action_ Otherwise you must explain why no action is proposed.