Source · Prevention of Future Deaths

Phyllis Broomhead

Ref: 2015-0290 Date: 6 Jul 2015 Coroner: Nicola Mundy Area: South Yorkshire (East) Responses identified: 1 / 1 View PDF

Care home staff lacked training in head injury protocols and record-keeping, while safeguarding screening was insufficient. There's a systemic gap in monitoring high-risk residents when nursing care isn't deemed necessary, leaving them vulnerable.

Date 6 Jul 2015

56-day deadline 31 Aug 2015

Responses identified 1 of 1

Care Home Health related deaths

Coroner's concerns

AI summary

View full coroner's concerns

Staff employed at Lord Hardy Court EMI Residential Home require further training with regard to: the head injury protocol, how this should be followed and the importance of SO. Coroner'$ Court and Office; Doncaster Crown Court; College Road, Doncaster; DNI 3HS Tel 01302 320844 Fax 01302 364833 July day Mrs day doing record keeping: iii_ indicators and triggers to seek social worker input (2) With regard to the Safeguarding team, subject to the impact of any subsequent legislation, the importance of ensuring that any initial screening process following a referral is sufficiently detailed and objective to facilitate the making of safe, sound and informed decisions with regard to any future action which might be indicated or indeed before exiting the process. Furthermore, heard evidence that there were three types of home available; care homes EMI care homes and nursing homes. For residents who are clearly continuing to be at high risk of serious injury, as was the case here, consideration should be given to introducing or expanding any Iocal procedures or protocols to ensure closer scrutiny and monitoring of such residents' progress. seemed that although Mrs Broomhead was identified as of high risk of falls, as it was felt that her needs didn't amount to nursing needs there was no alternative but for her to remain in a care home_

Responses

1 respondent

Rotherham Borough Council Local Authority / Fire Service

11 Sep 2015 PDF

Action Planned

Rotherham Metropolitan Borough Council will provide a detailed action plan regarding recommendations made under Regulation 28, outlining actions taken, actions to be achieved, and timescales to conclude any uncompleted actions. (AI summary)

View full response

Dear Ms Mundy RE: Phyllis Broomhead, (Deceased) DOB: 05.03.1923 DOD: 09.06.2013 Onothe 6 July 2015 you concluded the inquest into the death of Phyllis Broomhead, recorded a narrative conclusion and submitted a report under You concerns about certain aspects of Mrs Broomhead's Regulation 28 to express the department care. Your report was received in to on 26
2015. You requested that the Local Authority respond to your report within 56 details of action taken or proposed to be taken, out the timetable for outlining original response time was extended to the 14th September 2015 action_ The to Jill Wetherall, Service by your office in a letter Manager; Safeguarding Adults dated 1s" September 2015. Please; find enclosed a detailed action plan of recommendations made under 28hiactions taken by Rotherham Metropolitan Borocgh Ceuation theadectioder havulbeien achieved and timescale to conclude any uncompleted actions these your approval: meet with

Report sections

Investigation and inquest

On 12/06/2013 | commenced an investigation into the death of Phyllis Broomhead, 90. The investigation concluded at the end of the inquest on 06 2015. Cause of death: Traumatic left sided subdural haemorrhage The conclusion of the inquest was a Narrative conclusion: Phyllis Broomhead became a resident at Lord Hardy Court in December 2012 due to her dementia and general care needs_ Despite multi-agency support she continued to suffer falls between 1 February 2013 and the time of her death_ Three of these falls led to significant injuries_ On 9 June she fell from her bed whilst trying to reach the toilet and sustained a head injury from which she died later that

Circumstances of the death

Mrs Phyllis Broomhead suffered from advanced brain disease (dementia) as a consequence of which she was admitted to the Lord Hardy Court EMI Residential Home on the 18th December 2012. The home cared for her general care needs and her dementia needs. Despite multi agency input Broomhead suffered several falls between the 11th December 2013 and her death on the 9th June 2013_ Of the falls she suffered three of them were significant and all required hospitalisation. Safeguarding Alert was raised at the time of the second significant injury which was exited the of the alert, after enquiries had been made. It was felt all appropriate measures were in place and Mrs Broomhead returned to Lord Hardy Court. The falls continued until final fatal fall on 9 June 2013. Measures in place were not fully implemented:

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you The Chief Executive, Rotherham Metropolitan Borough Council have the power to take such action.

Similar PFD reports

Shared signals

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Report details

Reference: 2015-0290
Date of report: 6 July 2015
Coroner: Nicola Mundy
Coroner area: South Yorkshire (East)

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 31 Aug 2015.

Sent to

Rotherham Metropolitan Borough Council

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.