Source · Prevention of Future Deaths
George Renshaw Brown
Ref: 2013-0230
Date: 16 Sep 2013
Coroner: John Pollard
Area: Manchester South
0 responses identified · 6 indexed addressees
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AI-generated concerns summaryThe coroner identified a lack of an efficient system for the speedy reassessment and transfer of patients whose condition is rapidly deteriorating, leading to delays in moving individuals to suitable alternative accommodation.
Date
16 Sep 2013
56-day deadline
24 Mar 2014 est.
estimated from the Judiciary.uk publication date
Responses identified
0 of 6
Coroner's concerns
The coroner identified a lack of an efficient system for the speedy reassessment and transfer of patients whose condition is rapidly deteriorating, leading to delays in moving individuals to suitable alternative accommodation.
View full coroner's concerns
The MATTERS OF CONCERN is as follows.
(1) There is clear evidence given that Mr Brown was placed, properly, at Mayfield Care Home and that Mayfield Care Home were looking after him within the capabilities of that type of establishment: It soon became apparent to the Manager of that Care that were unable to meet the needs of Mr Brown's advancing dementia and whilst she brought this to the attention of the appropriate authorities nonetheless it took several months to have him moved to a suitable alternative accommodation There seemed to be no or no proper and efficient system in place for a speedy re-assessment and transfer of patients whose condition is deteriorating_rapidly: To Home they
(1) There is clear evidence given that Mr Brown was placed, properly, at Mayfield Care Home and that Mayfield Care Home were looking after him within the capabilities of that type of establishment: It soon became apparent to the Manager of that Care that were unable to meet the needs of Mr Brown's advancing dementia and whilst she brought this to the attention of the appropriate authorities nonetheless it took several months to have him moved to a suitable alternative accommodation There seemed to be no or no proper and efficient system in place for a speedy re-assessment and transfer of patients whose condition is deteriorating_rapidly: To Home they
Report sections
Investigation and inquest
On March 2013 commenced an investigation into the death of George Renshaw Brown who was born on 13 January 1925 and the investigation concluded at the end of the Inquest on 30 August 2013. The conclusion of the Inquest was that the deceased died from 1a) Pneumonia due to 1b) Cervical spine fracture and under Part Il: Acute on chronic bilateral cerebral haematoma and dementia and the conclusion reached by me was that of Accidental Death:
Circumstances of the death
On Sunday 17 February 2013 the deceased, who was a resident at Mayfield Care Home, left the premises via a fire door and fell down some concrete steps, He fractured his cervical spine and thereafter developed pneumonia leading to his death:
Action should be taken
In my opinion action should be taken t0 prevent future deaths and believe you and your organisation have the power t0 take such action.
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Report details
- Reference
- 2013-0230
- Date of report
- 16 September 2013
- Coroner
- John Pollard
- Coroner area
- Manchester South
Responses identified
Responses identified
0 of 6
6 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 24 Mar 2014 (estimated from the Judiciary.uk publication date).
Sent to
- Bromleys Solicitors
- Care Quality Commission
- Fentons Solicitors
- Manchester Clinical Commissioning Group
- Mayfield Care Home
- Trafford Borough Council