Lillian Rose Robinson · Prevention of Future Deaths report

On 22/1/13 I opened an inquest into the death of Lillian Rose Robinson who, at the date of her death was aged 89 years. The inquest was resumed and concluded on 15th and 16th January 2014.
I found that the cause of death to be: -
1a. Bronchopneumonia
I concluded with a Narrative finding

On 31/10/12, Lillian Rose Robinson was admitted to Brockhurst Care Home for intermediary care. On 27/10/12 she was transferred to Upper Halliford nursing home where she was found to have deteriorated and she succumbed and died from bronchopneumonia on 28/12/12.

• Lack of communication between hospital and home re mental capacity assessment
• Unqualified medical carers evaluating the appropriateness of capacity in patients with mild/moderate dementia
• Poor note taking and continuity of patient care notes

At the inquest I heard very helpful evidence from ████████ I would be obliged if you could confirm that steps have been taken to address these concerns.