Source · Prevention of Future Deaths

Charles Lawrence

Ref: 2014-0342 Date: 25 Jul 2014 Coroner: David Horsley Area: Portsmouth & South East Hampshire Responses identified: 1 / 1 View PDF

The care home lacks a critical protocol to ensure a doctor examines residents who experience multiple falls within a 24-hour period, indicating a gap in immediate medical assessment for recurrent fallers.

Date 25 Jul 2014

56-day deadline 19 Sep 2014 est.

Responses identified 1 of 1

Care Home Health related deaths

Coroner's concerns

AI summary

View full coroner's concerns

_ Alexandra Rose Care Home does not have a protocol of calling out a doctor to examine a resident who suffers more than one fall in a 24 hour period. and day and May

Responses

1 respondent

Alexandra Rose Residential Care Home Other

5 Aug 2014 PDF

Action Taken

The care home implemented a 'falls alert' notification to be faxed to residents' doctors after more than one fall in 24 hours, and included this protocol in resident care plans. (AI summary)

View full response

Dear Mr Horsley Re: Inquest Zth July 2014_Mr Charles Lawrence_Coroner' s Regulation 28 Report Further to vour Regulation Report towards Alexandra Rose Care Home am writing to you with the actions the Company are to take The home has devised a 'falls alert' notification that will be faxed to the residents doctors surgery should fall more than once over a 24 hour period. This has been agreed by the Drayton Medical Practice, although have not as vet received any further response from the two other surgeries that the home uses. In this case the home will call these surgeries direct should a second fall arise within that period. We currently have over 25 residents registered at Drayton Medical Practice which is a substantial amount so hope that you agree that this is the most important surgery to support us with this protocol: Further to this document; each resident now has this Protocol in their care plans under there mobility and falls risk assessments_ have enclosed a copy of the falls alert notification form, which / hope satisfies your requirements under note 5 of your report:

Report sections

Investigation and inquest

On 30"h May 2013 commenced an investigation into the death of Charles Cecil Lawrence, aged 89 The investigation concluded at the end of the inquest on 7th July 2014. The conclusion of the inquest was Mr Lawrence died due to an Accident: The medical cause of this death was: la: Spinal Cord Compression Ib: Fractured Thoracic Vertebrae 2: Congestive Cardiac Failure and Pneumonia

Circumstances of the death

On 2nd April 2013 Charles Cecil Lawrence fell in the residential home where he lived. He was visited by his GP who noted no apparent injury to Mr Lawrence. Mr Lawrence fell again later that but his GP was not recalled: By 1 April 2013 Mr Lawrence was in increasing distress and his condition deteriorated his GP admitted him to Queen Alexandra Hospital, Portsmouth, where he was diagnosed as having sustained an untreatable spinal injury: He died at Queen Alexandra Hospital on 23rd 2013 at 06.40 hours_

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action:

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Report details

Reference: 2014-0342
Date of report: 25 July 2014
Coroner: David Horsley
Coroner area: Portsmouth & South East Hampshire

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: 19 Sep 2014 (estimated).

Sent to

Alexandra Rose Care Home

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.