Kathleen Eaton · Prevention of Future Deaths report

On 6th February 2015 I commenced an investigation into the death of Kathleen Eaton dob 18th December 1929. The investigation concluded on the 19th June 2015 and the conclusion was one of Accidental death. The medical cause of death was 1a Subdural and Subarachnoid Haemorrhage 1b Recurrent Falls 11. Congestive heart failure vertebra-basilar insufficiency

On the 26th January 2015 she fell in the bedroom of her home. She called her emergency carers by use of her alarm. The carer attended, used a blow-up ‘hoist’ (ELK) to raise her into a position where she could be put back to bed. The carer carried out peremptory checks and then left the deceased to await the arrival of her regular carers who were expected some two hours later. She was later taken to hospital where she was found to have suffered damage to and around her brain.

1. The emergency trust link officer employed by Peaks and Plains conceded that she had no formal training in assessing medical issues. In her statement she had said “I am fully first aid trained” yet in evidence it emerged that she had received this training after the date of his death. It would also appear that her earlier First Aid certificate may well have expired

2. She stated that she was unaware of any set policies or procedures in place for assessing and dealing with head injury cases. There was nothing in writing advising as to when it is appropriate and/or necessary to summon an ambulance.

3. The property where the deceased was resident is situated in Disley and I was told it is approximately 15 miles from the base in Macclesfield. I was also told that the officer was able to travel there in 20 minutes in what she had already told me were snowy conditions. I find it hard to believe and wonder whether an adequate service can ever be provided at that geographical distance.