Source · Prevention of Future Deaths
John William Tugwell
Ref: 2013-0319
Date: 1 Dec 2013
Coroner: Martin Fleming
Area: Surrey
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner noted that a resident identified as a falls risk, with a history of previous falls, was allowed unsupervised access to stairs within the care home.
Date
1 Dec 2013
56-day deadline
19 Apr 2014 est.
estimated from the Judiciary.uk publication date
Responses identified
0 of 1
Coroner's concerns
The coroner noted that a resident identified as a falls risk, with a history of previous falls, was allowed unsupervised access to stairs within the care home.
View full coroner's concerns
During the course of the inquest the evidence revealed a matter that gave rise to concern and which, in my opinion, there is a risk that future deaths could occur by reason thereof unless action is taken.
The MATTER OF CONCERN is as follows. –
Although Mr Tugwell was clearly a falls risk given his documented history of previous falls at the home, he was allowed unsupervised access to the two sets of stairs at the home.
I would be grateful if you could re consider the appropriateness of allowing such vulnerable and unsupervised residents access to the stairs given the potential for serious injury.
The MATTER OF CONCERN is as follows. –
Although Mr Tugwell was clearly a falls risk given his documented history of previous falls at the home, he was allowed unsupervised access to the two sets of stairs at the home.
I would be grateful if you could re consider the appropriateness of allowing such vulnerable and unsupervised residents access to the stairs given the potential for serious injury.
Report sections
Investigation and inquest
On 16th April 2013 I opened an inquest into the death of John William Tugwell who, at the date of his deaths was aged 79 years. The inquest was resumed and concluded on 22nd November 2013 I found that the cause of death to be: ‐ 1a. Bilateral lobar pneumonia 1b. Acute subdural haemorrhage and cortical contusions I concluded with Accidental Death.
Circumstances of the death
On 6th April 2013 Mr John William Tugwell was found at the bottom of the stairs following an unwitnessed fall at the nursing home where he was a resident. At the hospital he was found to have sustained skull fractures and an extra cranial scalp haematoma. Very sadly he was not considered fit for surgery and he subsequently succumbed to his injuries on 9th April 2013. RT3763 RT3763
Copies sent to
I have sent a copy of this report toSurrey PoliceSurrey Safeguarding AdultsChief CoronerCoroners Society for England and WalesRT3763 DATED this 1st December 2013
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Report details
- Reference
- 2013-0319
- Date of report
- 1 December 2013
- Coroner
- Martin Fleming
- Coroner area
- Surrey
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: 19 Apr 2014 (estimated from the Judiciary.uk publication date).
Sent to
- Coombe Dingle Nursing Home