Shirley FROGGTT · Prevention of Future Deaths report

On 23/11/2018 I commenced an investigation into the death of Shirley FROGGTT aged 84. The investigation concluded at the end of the inquest on 19 February 2021. The conclusion of the inquest was:

I a Bronchopneumonia

I b Fractured Left Femur (Operated 25/09/2018)

I c

II Osteopenia

Shirley Froggtt died on the eighth of November 2018 at the Old Lodge Nursing Home, Sandypits Lane, Etwall, Derbyshire.

Conclusion of the Coroner as to the death:
Shirley Froggtt died of bronchopneumonia resulting from a fractured left femur which was sustained in a fall from a wheelchair in a Nursing Home. Despite a care plan being in place, requiring Mrs Froggtt to be secured in her wheelchair, to prevent her from falling, the lap-strap was not applied as it was missing a buckle. The continued use of the wheelchair and the non-observance of the care plan were gross failures. As such Mrs Froggtt died from an accident contributed to by neglect.

On the evidence heard at inquest I was not satisfied that New Lodge Nursing Home had any robust systems in place to ensure compliance with care plans, policies and protocols.