Source · Prevention of Future Deaths

Annie Jones

Ref: 2013-0306 Date: 20 Nov 2013 Coroner: John Gittins Area: North Wales (East & Central) Responses identified: 1 / 1 View PDF

An inadequate mobility assessment led to the unsafe use of a stand aid for a non-weight-bearing resident. Staff lacked awareness of limitations and proper training, posing a significant risk of injury to vulnerable patients.

Date 20 Nov 2013

56-day deadline 15 Jan 2014

Responses identified 1 of 1

Care Home Health related deaths

Coroner's concerns

AI summary

View full coroner's concerns

During the course of the investigation it became apparent that Mrs Jones had sustained severe bruising to her upper body following the fall referred in paragraph 4 and that she should never have been placed in this stand aid" which required her to some extent weight bearing: Mrs Jones had not been weigh bearing for over three years. An inadequate assessment of the mobility of Mrs Jones was made The stand aid was unsafe for use with Mrs Jones Not all staff were aware of the limitations of Mrs Jones with regard to her mobility Not all staff were able to operate the stand safely and the

Whilst the incident did not contribute to this death feel it is necessary to bring this to your attention 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:

Responses

1 respondent

Abbey Dale House

PDF

Action Taken

Abbey Dale House created an updated document providing a snapshot of each resident's needs, including a summary person handling plan, readily available to all staff. The care home adopted the All-Wales Manual Handling Passport, an intensive manual-handling training programme. (AI summary)

View full response

Dear Sirs Re: Inquest of Annie Ceinwen Jones 25th September_2013 acknowledge receipt of your letter of 2Oth November; together with the Regulation 28 Report; and enclose my response. trust that this is self-explanatory, but please do not hesitate in contacting me if you require any clarification:

Report sections

Investigation and inquest

On the 4th of December 2012 commenced an investigation into the death of Annie Ceinwen Jones (DOB 11.11.14,DOD 2.12.12). The investigation concluded at the end of the inquest on the 25th of September 2013 conducted by Assistant Coroner Nicola Jones. The conclusion of the inquest was Natural Causes and the medical cause of death was 1(a) Bronchopneumonia, Vulvulus of Sigmoid Colon with Infarction and Intestinal Obstruction:

Circumstances of the death

The Deceased had been admitted to Ysbyty Glan Clwyd on the 1st of December 2012 feeling very poorly and with extensive bruising sustained in a fall from a "stand aid" used to assist her with her toileting needs. An autopsy was undertaken and above medical cause of death was established_

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_

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2013-0306
Date of report: 20 November 2013
Coroner: John Gittins
Coroner area: North Wales (East & Central)

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: 15 Jan 2014.

Sent to

Abbeydale Residential Home, Princes Drive, Colwyn BayRoad

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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