Source · Prevention of Future Deaths

Wilhelmina Isobel Newton

Ref: 2013-0283 Date: 31 Oct 2013 Coroner: David Roberts Area: Cumbria (North & West) Responses identified: 1 / 2 View PDF

The care home lacked clear written protocols and guidance for staff on responding to head injuries in elderly residents, particularly those on anti-clotting medication.

Date 31 Oct 2013

56-day deadline 26 Dec 2013

Responses identified 1 of 2

Care Home Health related deaths

Coroner's concerns

AI summary

The care home lacked clear written protocols and guidance for staff on responding to head injuries in elderly residents, particularly those on anti-clotting medication.

View full coroner's concerns

On the evidence heard it appeared there was no clear written plan , protocol or guidance to the staff as to how they should respond to a potential head injury to an elderly resident, particularly one receiving medication which had the potential to affect the blood’s clotting ability: the absence of such guidance may apply to other residential homes operated by the Council

Responses

1 respondent

Cumbria County Council Local Authority / Fire Service

PDF

Action Taken

Cumbria County Council has reviewed the issues regarding procedures to be followed when a resident sustains or is suspected of sustaining a head injury and updated their policy, embedding it throughout the organisation and with independent providers. (AI summary)

View full response

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Report sections

Investigation and inquest

On 13th May 2013 I commenced an investigation into the death of Wilhelmina Isobel Newton, 98. The investigation concluded at the end of the inquest on 21st October 2013. The conclusion of the inquest was Medical cause of death 1a) Subdural Haematoma b) Fall Conclusion: On the 14th May 2013 in her room at Grisedale Croft Residential Home the deceased was put into bed at about 03.00 hrs. At 04.30 hrs she shouted and was found to be lying on the floor next to her bed. Later that morning she was found to be unrousable and was admitted to Cumberland Infirmary where she died on 15th May 2013. She died as the result of an Accident.

Circumstances of the death

The deceased had a history of falls both before and after becoming a resident at Grisedale Croft. She had fallen out of bed and banged her head at 04.30 hours. She was not attended by a nurse until 09.45 hours shortly after which an ambulance was summoned. She was prescribed regular aspirin. S:\Statutory functions\Rule 43 and PFD\Post April 2013\Newton 2013-0283.doc

Action should be taken

by way of a review of the procedures to be followed when a resident is suspected of sustaining a head injury particularly when that person is prescribed medication which affects the blood’s ability to clot.

Copies sent to

Chairman, The Adult Safeguarding Board Public Protection Unit, Cumbria Constabulary

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Report details

Reference: 2013-0283
Date of report: 31 October 2013
Coroner: David Roberts
Coroner area: Cumbria (North & West)

Responses identified

Responses identified 1 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 26 Dec 2013.

Sent to

Cumbria County Council Carlisle

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.