Source · Prevention of Future Deaths
Doris Taylor
Ref: 2014-0164
Date: 9 Apr 2014
Coroner: John Pollard
Area: Manchester (South)
Responses identified: 0 / 1
View PDF
The coroner noted that staff training should include a full and clear understanding as to what constitutes a reportable incident and the managers should be aware of their duty to report such. The door-closers on all doors should be in a safe working condition.
Date
9 Apr 2014
56-day deadline
5 Jun 2014
Responses identified
0 of 1
Coroner's concerns
The coroner noted that staff training should include a full and clear understanding as to what constitutes a reportable incident and the managers should be aware of their duty to report such. The door-closers on all doors should be in a safe working condition.
View full coroner's concerns
_ Staff training should include a full and clear understanding as to what constitutes reportable incident and the managers should be aware of their duty to report such The door-closers on all doors in such an establishment should be in a safe working condition, and of such 'strength' as to be efficient in causing the door to close at the same time not so 'strong' as to make it dangerous as they close (as to knock over the person as happened to Mrs Taylor). due being yet
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:
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:
Report sections
Investigation and inquest
On 7th January 2014 commenced an investigation into the death of Doris Taylor dob 3rd October 1931. The investigation concluded on the 31st March 2014 and the conclusion was one of Accidental Death: The medical cause of death was 1a Pneumonia and multi organ failure 1b Fracture neck of femur (operated) and Il Meningioma, intracranial haemorrhage and hypertension:
Circumstances of the death
On the 20"h November 2013 she was admitted to Marbury House Care Home to decreased mobility and pains in her back: She was assessed as at high risk of falling: During the course of her stay she suffered 3 separate falls. It would appear that the second of these falls was due to a defective door-closer which caused the door to close knocking Mrs Taylor over. The senior member of staff who attended the inquest to give evidence was unaware of the need to report such incidents to the Health and Safety Executive and further stated that she_was not trained as t0 which matters are reportable under RIDDOR
Similar PFD reports
Related inquiry recommendations
Post Office Horizon Inquiry
Apply best offer principle equally in GLOS
Fuller Inquiry
Local authority review third-party contracts
Fuller Inquiry
Contractual incident notification requirement
Fuller Inquiry
Local authority contractor governance assurance
Fuller Inquiry
Security breaches reviewed by expert with action plans
Fuller Inquiry
Formalise multi-organisation arrangements
IICSA
Church in Wales provincial safeguarding officers
IICSA
Amend Canon C30 on safeguarding due regard
IICSA
Guidance on DBS for overseas work
IICSA
Religious organisation child protection policies
Report details
- Reference
- 2014-0164
- Date of report
- 9 April 2014
- 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: 5 Jun 2014.
Sent to
- Borough Care Limited