Source · Prevention of Future Deaths

Meryl Parry

Ref: 2015-0259 Date: 8 Jul 2015 Coroner: Robert Chapman Area: Cumbria Responses identified: 1 / 2 View PDF

A lack of mandatory system for residential homes to seek Social Services advice before discharging residents creates a serious risk that discharged individuals will not have appropriate safety and welfare arrangements in place.

Date 8 Jul 2015

56-day deadline 2 Sep 2015

Responses identified 1 of 2

Other related deaths

Coroner's concerns

AI summary

View full coroner's concerns

There appears to be no system in place whereby the managers of a residential home are required to seek advice from Social Services before discharging resident (2) There is therefore a serious risk that there are no appropriate arrangements in place to ensure the safety and welfare of the resident after discharge
3) The system for seeking advice from Social Services should apply irrespective of whether Social Services had placed the resident at the home or whether the placement had been a private one. In the latter case it is likely that a social worker will have been aware of, or had some involvement in, the placement ACTION SHOULD BE TAKEN: Cumbria County Council Social Services should provide general guidance to residential homes in which it is required that if a residential home is considering discharging a resident then before do so should seek advice from Social Services so that Social Services can be satisfied that there are appropriate arrangements in place for the safety and wellbeing of the resident after discharge, and the appropriate time for that discharge. This would apply if Social Services had been responsible for placing the resident within the residential home, and also if they had been placed privately without any Social Services direct involvement; Green Lane House That you should provide to Cumbria Social Services confirmation that your procedures have been changed so that you follow the guidance set out above You should send me a copy of the confirmation that you send to Cumbria Social Services

Responses

1 respondent

Greenlane Care Homes Limited

4 Sep 2015 PDF

Action Taken

Greenlane Care Homes Limited confirms their Discharge Pack has been changed to include the procedure to follow for an unanticipated discharge. (AI summary)

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Dear Mr Woodhouse, am writing t0 You aS instructed by R Chapman, HM Assistant Coroner to confirm that our Discharge Pack has been changed. It now includes the procedure to follow for an unanticipated discharge, in accordance with your letter dated 4th September 2015. Please find enclosed a copy _

Report sections

Investigation and inquest

On 19"h September 2014 commenced an investigation into the death of Meryl aged 80. The investigation concluded at the end of the Inquest on 6"h July 2015. The conclusion of the inquest was: The Cause of death was:
1.a. Plastic asphyxia The Conclusion of the Coroner was: Mrs was unlawfully killed

Circumstances of the death

Mrs Parry had suffered from memory loss from about 2006 and in 2012 she was diagnosed as suffering from Alzheimer's disease She lived with her husband; Her abilities declined and this coincided with a substantial downturn in Mrs Parry'$ own health: In August 201 Jafter discussion with Parry's social worker and her GP had decided that Mrs Parry should be accommodated in a residential home. He had spent a considerable amount of time looking for the home that he felt would be best able to accommodate his wife. One of the features of her disease was that Parry tended to wander away from home It was agreed that on 1st September 2014 Mrs would be assessed by lat the Green Lane House Residential Home, and that she would stay there for at least respite care whilst hhad hospital treatment Mrs Parry was admitted to Green Land House on the 1 September 2014 , On the afternoon of 1st September 2014 Mrs managed to leave Green Lane House unobserved, and was found walking into Brampton She was returned to Green Lane House and a decision was made by Ithat it was not going to be possible to safely accommodate Mrs Itelephoned who was tOO tired to come to collect her, so she was fed, bathed, and put into her night clothes and returned to her home address. This occurred about 8pm on 1 September: felephoned a number of residential homes, and no one was able to take wife that night Hedid not believe that Mrs Parry would be happyand able to survive_ Care, Parry, bag Parry Mrs Mrs Parry Parry Parry. his

Tiving in a secure dementia unit: He was suffering from heightened tension, anxiety and stress, and he killed Mrs Parry:

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Report details

Reference: 2015-0259
Date of report: 8 July 2015
Coroner: Robert Chapman
Coroner area: Cumbria

Responses identified

Responses identified 1 of 2

1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 2 Sep 2015.

Sent to

Cumbria County Council

Green Lane Care Homes Limited

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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