Source · Prevention of Future Deaths
Ian Morley
Ref: 2015-0320
Date: 17 Aug 2015
Coroner: Chinyere Inyama
Area: London (West)
Responses identified: 0 / 2
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A patient's deteriorating condition failed to trigger a necessary fresh risk assessment, compounded by inadequate fire risk management at the care facility.
Date
17 Aug 2015
56-day deadline
12 Oct 2015
Responses identified
0 of 2
Coroner's concerns
A patient's deteriorating condition failed to trigger a necessary fresh risk assessment, compounded by inadequate fire risk management at the care facility.
View full coroner's concerns
1.The multiple sclerosis nurse who had been working with the deceased noted that his condition had deteriorated shortly before his death. This should have prompted a fresh risk assessment but it was not evident that it did, in fact, do so. There was inadequate fire risk management at Greenrod Place
Report sections
Investigation and inquest
On 6'h August 2014 commenced an investigation into the death of [Ian David Morley age 57. The investigation concluded at the end of the inquest on 14# May 2015. The conclusion of the inquest was in narrative form including the following words His death was clearly the result of an accident but the risk of the accident occurring was not adequately managed at the time"_
Circumstances of the death
The deceased was wheelchair bound and resident in supported accommodation with a history of multiple sclerosis_ His carers found him alight after_ it is presumed, he dropped cigarette onto the seat of his wheelchair which was covered by a towel rather than a fire retardant seat cover . His condition had deteriorated prior to his death_
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action: The action for the Adult Social Care Service should be to either review the existing or develop a new protocol for sharing of information between specialist nurses, GPs, care homes and Adult Social Services such that risk management of people being looked after is kept current and optimal. The action from Greenrod Place is to organise a 'Home Fire Safety Visit' in accordance with the advicein the attached letter from_ Group_Manager NE Area Fire
Safety Regulation, East Ham Offices 0f the LFB. For both recipients of this PFD , they must adopt the use of the attached LFB Home Fire Safety Risk Referral Matrix in all their residential premises
Safety Regulation, East Ham Offices 0f the LFB. For both recipients of this PFD , they must adopt the use of the attached LFB Home Fire Safety Risk Referral Matrix in all their residential premises
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Report details
- Reference
- 2015-0320
- Date of report
- 17 August 2015
- Coroner
- Chinyere Inyama
- Coroner area
- London (West)
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 Oct 2015.
Sent to
- Adult Social Services
- Greenrod Place