Source · Prevention of Future Deaths
Olive Nugent
Ref: 2015-0134
Date: 31 Mar 2015
Coroner: Karen Dilks
Area: Newcastle Upon Tyne
Responses identified: 0 / 1
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Falls activator device responses were delayed due to subjective prioritisation and insufficient staffing, particularly for non-verbal users, leaving vulnerable individuals without timely assistance.
Date
31 Mar 2015
56-day deadline
26 May 2015 est.
Responses identified
0 of 1
Coroner's concerns
Falls activator device responses were delayed due to subjective prioritisation and insufficient staffing, particularly for non-verbal users, leaving vulnerable individuals without timely assistance.
View full coroner's concerns
_ (1) Mrs Nugent critically injured in her home for 2 27 minutes without assistance or access to medical treatment: (2) Her falls activator device had activated automatically indicating that she had fallen.
(3) Her inability to respond verbally to call handlers via the device was a crucial factor in the decision not to prioritise her case. Priority was given to clients whose devices had activated in some cases at a time later than Lord Mayor $ Gallery, Civic Centrc: Barras Bridge; Ncwcastle Tyne; NEI 8QA Tel 0191 2777280 Fax 0191 2612952 City hours and lay Upon
Mrs Nugent s but who had been able to verbally respond to call handlers via their devices.
(5) The prioritising of response to device activation is entirely subjective and heavily dependent upon (a) staffing levels (b) the personal practices of individual team leaders (6) On 16" December 2014 there were insufficient staff to meet the demand for assistance This contributed to the delayed response to Mrs Nugent's needs A review of the Guidance to be adopted when responding to device activation was undertaken following Mrs Nugent's death.
(8) The Policy Document entitled "Mobile Response Time Targets, Prioritising Mobile Response and Escalation Process however, reaffirms that prioritisation of response remains a subjective process_ A proposed escalation process in the event of demand exceeding the capacity of available staff is dependent upon other agencies whose availability is not guaranteed or the subject of any Memo of Understanding: (9) The provision of Falls Detection Device is intended to ensure timely aid and assistance including medical treatment of injuries if required to vulnerable persons in the event of a fall: (1O)Further deaths could potentially occur in the future; particularly in cases of persons injured and unable to respond verbally to call handlers_ (11)Review of the Guidance and Document and staffing levels is necessary to reduce this risk
(3) Her inability to respond verbally to call handlers via the device was a crucial factor in the decision not to prioritise her case. Priority was given to clients whose devices had activated in some cases at a time later than Lord Mayor $ Gallery, Civic Centrc: Barras Bridge; Ncwcastle Tyne; NEI 8QA Tel 0191 2777280 Fax 0191 2612952 City hours and lay Upon
Mrs Nugent s but who had been able to verbally respond to call handlers via their devices.
(5) The prioritising of response to device activation is entirely subjective and heavily dependent upon (a) staffing levels (b) the personal practices of individual team leaders (6) On 16" December 2014 there were insufficient staff to meet the demand for assistance This contributed to the delayed response to Mrs Nugent's needs A review of the Guidance to be adopted when responding to device activation was undertaken following Mrs Nugent's death.
(8) The Policy Document entitled "Mobile Response Time Targets, Prioritising Mobile Response and Escalation Process however, reaffirms that prioritisation of response remains a subjective process_ A proposed escalation process in the event of demand exceeding the capacity of available staff is dependent upon other agencies whose availability is not guaranteed or the subject of any Memo of Understanding: (9) The provision of Falls Detection Device is intended to ensure timely aid and assistance including medical treatment of injuries if required to vulnerable persons in the event of a fall: (1O)Further deaths could potentially occur in the future; particularly in cases of persons injured and unable to respond verbally to call handlers_ (11)Review of the Guidance and Document and staffing levels is necessary to reduce this risk
Report sections
Investigation and inquest
On 18/12/2014 commenced an investigation into the death of Olive Nugent; 92 years old, dob 14/6/1922. The investigation concluded at the end of the inquest on 3Oth March 2015. The medical cause of death was established: 1a. Multiple Contusions Intracerebral Haemorrhage and diffuse Axonal Injury 1b. Head Injury (consistent with a fall) IL. Cerebrovascular Disease The conclusion of the inquest was accidental dearth.
Circumstances of the death
Olive Nugent lived independently with a care package including carer visits 4 times daily. She was provided with a falls detector device designed to automatically activate in the event of a fall. The device also had a facility for summoning help when required: Wardens were provided with guidance requiring response to device activation within 45 minutes_ On the 16th December 2014 Mrs Nugent fell down stairs at her home address_ Her device activated at 8.58am. No attendance by a warden occurred until 11.25am. Mrs Nugent had sustained an un-survivable brain injury that led to her death_
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
- 2015-0134
- Date of report
- 31 March 2015
- Coroner
- Karen Dilks
- Coroner area
- Newcastle Upon Tyne
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: 26 May 2015 (estimated).
Sent to
- South Tyneside Council