Joseph Kevin Lafferty · Prevention of Future Deaths report

On 25th October 2018, Christopher Murray, Assistant Coroner, opened an inquest into the death of Joseph Kevin Lafferty who died on 24th June 2018 at Wythenshawe Hospital, Manchester, at the age of 85 years. The investigation concluded with an inquest which I heard between 1st – 4th July 2019 and which concluded with a Narrative conclusion to the effect that Mr Lafferty died as a consequence of a fall at his care home which occurred after he left the building and gained access to an area of the grounds to which it was not intended he should have access, whilst unsupervised.

On 25th October 2018, Christopher Murray, Assistant Coroner, opened an inquest into the death of Joseph Kevin Lafferty who died on 24th June 2018 at Wythenshawe Hospital, Manchester, at the age of 85 years. The investigation concluded with an inquest which I heard between 1st – 4th July 2019 and which concluded with a Narrative conclusion to the effect that Mr Lafferty died as a consequence of a fall at his care home which occurred after he left the building and gained access to an area of the grounds to which it was not intended he should have access, whilst unsupervised.

Mr Lafferty was formally diagnosed with dementia in 2014. Over subsequent years, problems with his short term memory increased and his mobility declined. In January 2018, Mr Lafferty was admitted to hospital following a fall, and treated for an infection. It was appreciated that Mr Lafferty’s condition was now such that he could not safely return home.

Following assessments undertaken in hospital, it was identified Mr Lafferty required 24 hour EMI residential care. As such, on 1st May 2018, Mr Lafferty moved into The Cedars Rest Home, Bowden, Altrincham.

Whilst at The Cedars, Mr Lafferty was noted to be wander some. At around teatime on 11th June 2018, staff at the home realised Mr Lafferty was missing. A search ensued, and he was found outside of the care home in an area it was not intended he should have access to with serious injuries. An ambulance was called at 17:41 and arrived on scene approximately two hours later.

Mr Lafferty was taken to Wythenshawe Hospital where he subsequently died. A post mortem examination concluded Mr Lafferty died as a consequence of:

1) A) Bronchopneumonia with congestive cardiac failure; due to

1) B) Thoracic trauma on the background of ischaemic heart disease and dementia.

Mr Lafferty was formally diagnosed with dementia in 2014. Over subsequent years, problems with his short term memory increased and his mobility declined. In January 2018, Mr Lafferty was admitted to hospital following a fall, and treated for an infection. It was appreciated that Mr Lafferty’s condition was now such that he could not safely return home.

Following assessments undertaken in hospital, it was identified Mr Lafferty required 24 hour EMI residential care. As such, on 1st May 2018, Mr Lafferty moved into The Cedars Rest Home, Bowden, Altrincham.

Whilst at The Cedars, Mr Lafferty was noted to be wander some. At around teatime on 11th June 2018, staff at the home realised Mr Lafferty was missing. A search ensued, and he was found outside of the care home in an area it was not intended he should have access to with serious injuries. An ambulance was called at 17:41 and arrived on scene approximately two hours later.

Mr Lafferty was taken to Wythenshawe Hospital where he subsequently died. A post mortem examination concluded Mr Lafferty died as a consequence of:

1) A) Bronchopneumonia with congestive cardiac failure; due to

1) B) Thoracic trauma on the background of ischaemic heart disease and dementia.

Over the course of the inquest, evidence was heard to the effect that The Cedars Rest Home had been inspected by the Care Quality Commission in 2016 and assessed as ‘Good’. Following Mr Lafferty’s death, a further inspection took place and a rating of ‘Requires Improvement’ was arrived at.

It is a matter of concern that, according to the evidence of the Care Quality Commission Inspector who gave evidence at court, there is no requirement on inspectors to include external aspects of a registered premises in the course of a CQC inspection in every case.

Consideration should be given to such areas automatically forming part and parcel of a CQC inspection where these are routinely in use by residents in the course of the provision of regulated activities.

In the course of the inquest, evidence was heard to the effect that, like other ambulance services, North West Ambulance Service NHS Foundation Trust utilises a priority dispatch system to triage calls whereby the answers callers gave to standard questions determined the level of response provided, and the timescales within which a response can ordinarily be expected.

It is a matter of concern that, according to the evidence of the Care Quality Commission Inspector who gave evidence at court, there is no requirement on inspectors to include external aspects of a registered premises in the course of a CQC inspection in every case.

It is a matter of concern that the system in use at this and other ambulance Trusts does not specifically take into account the age of the patient when determining the speed and acuity of response to be provided.