Source · Prevention of Future Deaths

Anne Horner

Ref: 2015-0047 Date: 11 Feb 2015 Coroner: Simon Nelson Area: Manchester (North) Responses identified: 1 / 5 View PDF

The design of an outward-opening toilet cubicle door led to two identical head injuries within six weeks, indicating a systemic risk, especially as it contradicts disabled toilet design guidance.

Date 11 Feb 2015

56-day deadline 8 Apr 2015 est.

Responses identified 1 of 5

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

The design of an outward-opening toilet cubicle door led to two identical head injuries within six weeks, indicating a systemic risk, especially as it contradicts disabled toilet design guidance.

View full coroner's concerns

1. The deceased had been a resident at Oak Lodge Nursing Home for approximately 6 weeks prior to her death during which time she was able to access and use bathroom facilities that were close to the bedroom which she occupied.
2. At approximately 02:3ohrs on the 6 th March 2014 whilst Mrs Homer was within the toilet cubicle within the bathroom she sustained a minor head injury when the door to the cubicle struck her head as it was being opened by a Health Care Assistant who was undertaking room checks.
3. At approximately 05:30hrs on the 25 th March 2014 Mrs Homer was involved in a virtually identical incident, again whilst sitting within the toilet cubicle. Sadly later that morning she was found unresponsive and notwithstanding her transfer to the emergency department at Salford Royal Hospital, she was diagnosed as having an unsurvivable brain injury.
4. The evidence at Inquest confirmed that the bathroom facility which included the toilet cubicle was constructed in or about 1988 in compliance with the relevant Planning Permission and Building Regulations. I accept that the facility had been used on many previous occasions without incident. The fact however that a resident sustained injury on two separate occasions within a period of 6 weeks gives rise to concern. I anticipate that there are many establishments within England and Wales where toilet facilities are not dissimilar to those at Oak Lodge Nursing Home. I understand that separate guidance in relation to disabled toilet design suggests doors that open outwards to facilitate access if someone falls behind the door. Whilst photographic images produced at Inquest suggested adequate door clearance for a resident sitting normally on the toilet, that would not be so for an individual resident who sat / was slumped forward.

Responses

1 respondent

CQC Regulator / Inspectorate

20 Mar 2015 PDF

Action Taken

The CQC requested and received information from the provider, who confirmed the toilet in question has been decommissioned. They also inspected the home on an unannounced basis. (AI summary)

View full response

Dear Mr Nelson We were very sad to read about the death of Mrs Homer and the circumstances in which she died. Thank you for your report and the requirement for us to review what actions should be taken to try to prevent the occurrence or continuation of such circumstances in the future. Please treat this letter as the formal response of the Care Quality Commission (‘CQC’) to your report dated 11 February 2015. In terms of the actions that we have taken since theevent , we have been in dialogue with the provider requesting information relating to the incident. This has included requiring information from the provider under Section 64 of the Health and Social Care Act 2008. This information has now been provided. The provider has confirmed to us in writing that the toilet has been decommissioned and is no longer in use. We note your comment relating to toilet doors opening outwards. It seems to us that it would not be appropriate for the CQC to provide any expert comment in this area. We respecifully suggest that it would be more appropriate for the Building Control department of the Bury Metropolitan Borough Council to advise on such matters. We are mindful on the one hand that a door opening outwards into a corridor might reduce the risk of a person using the toilet striking their head against an opened door while increasing accessibility in the event of a fall. On the other hand, we also recognise that outward-opening doors may pose inherent risks to passers-by outside a toilet and especially so where a service is frequented by people who may have a visual impairment or mobility problems. It is the responsibility of the service provider to manage the risks posed by whichever mechanism it implements to ensure the welfare and safety of service users. Registered office: Finsbury Tower, 103-105 Bunhill Row, London EC1Y 8TG

CareQuality Commission In terms of further actions that we have undertaken to address concerns highlighted in your report, the CQC has also inspected the home on an unannounced basis. The resultant report is currently in draft format and will shortly to be sent to the provider for comment and any factual accuracy representations. We have identified a number of areas the provider needs to address within the care home although none relate to the concerns raised in your report. If you wish we will send a copy of the report to you once it has been published. We hope that this letter adequately sets out the steps that the CQC has taken to address the concerns identified in your report following the inquest following into Mrs Homer’s very sad death. If we can be any further assistance please do not hesitate to contact us.

Report sections

Investigation and inquest

On the 7 th April 2014 I commenced an investigation into the death of Anne Homer for whom the cause of death had been given as being that of la) Traumatic Acute Subdural Haemorrhage with Renal Cell Carcinoma with Lung Metastases; Anticoagulation Therapy, whilst not causative of death, being contributory factors under 2. At an Inquest at the Rochdale Coroners Court Heywood on the 22 nd January 2015, the following conclusion was reached ‘against a background of increasing frailty of health and use of anti-coagulation therapy Anne Homer died at The Salford Royal Hospital on the 25 th March 2014 from a traumatic head injury precipitated initially by inadvertent impact with a toilet door which was being opened at Oak Lodge Care Home at approximately 05:l5hrs that day but which may have been aggravated by subsequent trauma following her collapse at approximately 09:40hrs that day whilst at the Care Home’.

Circumstances of the death

As above

Action should be taken

In my opinion action should be taken to consider legislation that would prevent fatalities occurring in similar circumstances and I believe each of you respectively have the power to take such action.

Copies sent to

1. Department of Health2. Bury MBC3. Care Quality Commission4. Messrs. Latimer Lee Solicitors on behalf of Oak Lodge Care Home

Similar PFD reports

Shared signals

Related inquiry recommendations

Similar themes

Fuller Inquiry Care homes in scope for new regulatory regime

Report details

Reference: 2015-0047
Date of report: 11 February 2015
Coroner: Simon Nelson
Coroner area: Manchester (North)

Responses identified

Responses identified 1 of 5

4 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 8 Apr 2015 (estimated).

Sent to

Bury Metropolitan Borough Council

Care Quality Commission

Department of Health and Social Care

Messrs. Latimer Lee Solicitors

Oak Lodge Care Home

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.