Source · Prevention of Future Deaths
Sybil Roberts
Ref: 2014-0402
Date: 12 Sep 2014
Coroner: John Gittins
Area: North Wales (East & Central)
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner noted no referral to a GP for a falls risk assessment upon admission, despite Mrs. Roberts' declining condition. Additionally, her care plan and falls risk were not reassessed or updated after her return from hospital following a first fall.
Date
12 Sep 2014
56-day deadline
7 Nov 2014
stated in the report
Responses identified
0 of 1
Coroner's concerns
The coroner noted no referral to a GP for a falls risk assessment upon admission, despite Mrs. Roberts' declining condition. Additionally, her care plan and falls risk were not reassessed or updated after her return from hospital following a first fall.
View full coroner's concerns
During the course of the investigation it became apparent that although Mrs Roberts had been assessed upon her admission to the residential home, there had not been a referral to her GP (as would be normal practice at this home) for a further falls risk assessment: This is despite an acknowiedgement that her condition was declining prior to the first fall. Furthermore her care plan and falls risk had not been reassessed and updated prior to her return to the home from hospital after the first fall and she sustained her second fracture only two days later. An inadequate assessment of the mobility of Mrs Roberts was made and feel it is necessary to this to your attention due to the fragile and vulnerable nature of other patients cared for at the home for whom an injury in these circumstances could result in death and bring
Report sections
Investigation and inquest
On the 18th of March 2014 commenced an investigation into the death of Sybil Roberts (DOB 03.09.24,DOD 15.03.14)_ The investigation concluded at the end of the inquest on the 4th of September 2014. The conclusion of the inquest was that of an Accidental Death and the medical cause of death was 1(a) Right Lower Lobe Pneumonia 2 Fractured Right Neck of Femur (Operated)
Circumstances of the death
The Deceased fell in her care home on the 30th of December 2013 and then again on the 1sl of February 2014 sustaining a fractured hip on each occasion and these injuries contributed to her subsequent death at the Maelor Hospital Wrexham on the 15th of March 2014_
Action should be taken
In my opinion action should be taken to prevent future deaths and believe your organisations have the power to take such action:
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Report details
- Reference
- 2014-0402
- Date of report
- 12 September 2014
- Coroner
- John Gittins
- Coroner area
- North Wales (East & Central)
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: 7 Nov 2014 (stated in the report).
Sent to
- Manor Park Residential Home