Source · Prevention of Future Deaths

Kathleen Eaton

Ref: 2015-0236 Date: 22 Jun 2015 Coroner: John Pollard Area: Manchester (South) Responses identified: 0 / 1 View PDF

An emergency trust link officer lacked formal medical assessment training and head injury policies, with no written guidance for ambulance summoning, raising doubts about the adequacy of emergency response from a distant base.

Date 22 Jun 2015
56-day deadline 17 Aug 2015 est.
Responses identified 0 of 1
Care Home Health related deaths

Coroner's concerns

AI summary
An emergency trust link officer lacked formal medical assessment training and head injury policies, with no written guidance for ambulance summoning, raising doubts about the adequacy of emergency response from a distant base.
View full coroner's concerns
_ The emergency trust link officer employed by Peaks and Plains conceded that she had no formal training in assessing medical issues. In her statement she had said am fully first aid trained" yet in evidence it emerged that she had received this training after the date of this death. It would also appear that her earlier First Aid certificate may well have expired She stated that she was unaware of any set policies or procedures in place for assessing and dealing with head injury cases. There was in writing advising as to when it is appropriate andlor necessary to summon an ambulance The property where the deceased was resident is situated in Disley and was told it is approximately 15 miles from the base in Macclesfield. was also told that the officer was able to travel there in 20 minutes in what she had already nothing told me were snowy conditions. find this hard to believe and wonder whether an adequate service can ever be provided at that geographical distance

Report sections

Investigation and inquest
On 6th February 2015 | commenced an investigation into the death of Kathleen Eaton dob 18"h December 1929_ The investigation concluded on the 19"h June 2015 and the conclusion was one of Accidental death. The medical cause of death was Ia Subdural and Subarachnoid Haemorrhage 1b Recurrent Falls 11. Congestive heart failure vertebra-basilar insufficiency CIRCUMSTANCES OF THE DEATH: On the 26 January 2015 she fell in the bedroom of her home. She called her emergency carers by use of her alarm: The carer attended used a blow-up 'hoist' (ELK) to raise her into a position where she could be put back to bed. The carer carried out peremptory checks and then left the deceased to await the arrival of her regular carers who were expected some two hours later: She was later taken to hospital where she was found to have suffered damage to and around her brain:
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action_

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Report details

Reference
2015-0236
Date of report
22 June 2015
Coroner
John Pollard
Coroner area
Manchester (South)

Responses identified

Responses identified 0 of 1
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 17 Aug 2015 (estimated).

Sent to

Peaks and Plains Housing Trust

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