Averil Skoric · Prevention of Future Deaths report

On 5th March 2018 I commenced an investigation into the death of Averil Skoric. The investigation concluded on the 2nd October 2019 and the conclusion was one of Narrative: Died from complications of positional asphyxia contributed to by positioning and her underlying frailty. The medical cause of death was: 1a) Bronchopneumonia with Positional Asphyxia on a background of Frailty and Vascular Dementia; II) Chronic Obstructive Pulmonary Disease

Averil Skoric had vascular dementia and had become increasingly frail in the months prior to her death. As a result her mobility was very limited. On 3rd March 2018 she was put to bed on her back in the care home where she was residing. On 4th March 2018 she was found on her front. On the balance of probabilities she had rolled onto her front having been left on her side in a way that made it easy for her to move into an unsafe sleeping position. She had died from positional asphyxia as a result.

The inquest was told that:

Mrs Skoric was a vulnerable resident who lacked capacity. Once she was on her front she was unable to move herself back into a safe sleeping position.

She had to be regularly moved during the course of a night to check to see if she needed changing. There was no clear guidance available to care home staff locally or nationally about safe sleeping positioning of vulnerable adults in their care to avoid this cadre of adults being placed in a position which created an increased risk of unsafe sleeping.