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Source · Prevention of Future Deaths

Wilhelmina Isobel Newton

Ref: 2013-0283 Date: 31 Oct 2013 Coroner: David Roberts Area: Cumbria (North & West) 1 response identified · 2 indexed addressees View PDF

AI-generated concerns summaryThe coroner noted the absence of a clear written plan or guidance for staff regarding responses to head injuries in elderly residents, particularly those on anti-clotting medication, a gap that may affect other council-operated homes.

Date 31 Oct 2013
56-day deadline 26 Dec 2013 stated in the report
Responses identified 1 of 2
Care Home Health related deaths

Coroner's concerns

AI summary
The coroner noted the absence of a clear written plan or guidance for staff regarding responses to head injuries in elderly residents, particularly those on anti-clotting medication, a gap that may affect other council-operated homes.
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
PDF
AI-classified response stance Action Taken
AI-generated response summary

• Cumbria County Council has reviewed the issue of protocols for head injuries in elderly residents, particularly those on anti-clotting medication. • New guidance has been developed by Cumbria County Council to identify actions to be taken should such an event occur. • A copy of the policy has been enclosed for reference and will be cascaded throughout the organisation and to independent sector providers via the Cumbria Care Sector Alliance.

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 (stated in the report).

Sent to

Cumbria County Council Carlisle
Cumbria County Council Carlisle

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

Contains public sector information licensed under the Open Government Licence v3.0.