Source · Prevention of Future Deaths
Eliza Simpson
Date: 27 Aug 2015
Coroner: Emma Brown
Area: Birmingham and Solihull
Responses identified: 0 / 2
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The care home lacked a system for renewing deprivation of liberty orders, risking unauthorized detention. The absence of CCTV also hindered investigation into an absconding resident.
Date
27 Aug 2015
56-day deadline
22 Oct 2015 est.
Responses identified
0 of 2
Coroner's concerns
The care home lacked a system for renewing deprivation of liberty orders, risking unauthorized detention. The absence of CCTV also hindered investigation into an absconding resident.
View full coroner's concerns
and Mrs_
(1) The Roseneath Care Home appeared to have no system for ensuring that when deprivation of liberty safeguarding orders expired the client was re-assessed to determine whether the need for an order persisted and, where appropriate , seeking further order. In this case the home would have had no legal authority to hold Mrs. Simpson if she had been detected attempting to leave the premises on the 2nd April 2015. The very of assessing Mrs. Simpson and renewing an application would have served to enforce to the Care Home and its staff the risk of her absconding and may have resulted in closer observation: Although the Roseneath Care Home has now closed if such a system is not standard in Care Homes this issue may arise elsewhere (2) The absence of CCTV hampered the Police investigation, although this is unlikely to have contributed to Mrs. Simpson's death this not always be the case and did mean that a very vulnerable member of society was left wondering around on her own when she might otherwise have been found with the aid of CCTV footage_
(1) The Roseneath Care Home appeared to have no system for ensuring that when deprivation of liberty safeguarding orders expired the client was re-assessed to determine whether the need for an order persisted and, where appropriate , seeking further order. In this case the home would have had no legal authority to hold Mrs. Simpson if she had been detected attempting to leave the premises on the 2nd April 2015. The very of assessing Mrs. Simpson and renewing an application would have served to enforce to the Care Home and its staff the risk of her absconding and may have resulted in closer observation: Although the Roseneath Care Home has now closed if such a system is not standard in Care Homes this issue may arise elsewhere (2) The absence of CCTV hampered the Police investigation, although this is unlikely to have contributed to Mrs. Simpson's death this not always be the case and did mean that a very vulnerable member of society was left wondering around on her own when she might otherwise have been found with the aid of CCTV footage_
Report sections
Investigation and inquest
On 17/h April 2015 | commenced an investigation into the death of Eliza Simpson: The investigation concluded at the end of the inquest on 19"h August 2015. The conclusion of the inquest was that the medical cause of death was ischaemic heart disease due to coronary artery disease and the conclusion as to the death was Accidental Death:
Circumstances of the death
Mrs Simpson left her residence Roseneath Care Home_ unobserved on the Znd April 2015. It is not known how Mrs Simpson was able to leave as all doors are locked on a magnetic locking system that was fully operational at the time_ Mrs Simpson ought to have been being closely monitored and should not have been able to leave the home unobserved due to the effects of dementia, she ought also to have been the subject of a Deprivation of Liberty Safeguarding order
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action. A review is required of the current requirements andlor guidelines for CCTV monitoring of exits in care homes the systems operated by Care Homes to keep track of the expiry date of DOLS orders so as to make further applications where necessary:
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Report details
- Date of report
- 27 August 2015
- Coroner
- Emma Brown
- Coroner area
- Birmingham and Solihull
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: 22 Oct 2015 (estimated).
Sent to
- Birmingham City Council
- Care Quality Commission