David Anthony Sketchley · Prevention of Future Deaths report

On the 27th July 2017 I commenced an investigation into the death of David Anthony Sketchley. The investigation concluded at the end of the inquest on 28th February 2018. The conclusion of the inquest was a narrative conclusion.

The following factors contributed to and caused the death of David Anthony Sketchley:
1) Inadequate Supervision
a) During incident an appropriate carer was absent during the incident
b) Lack of clarity in care plan. His supervision needs were unclear, as were the definitions of supervision.
2) Suitability of commode
a) There is insufficient to no evidence of David Anthony Sketchley’s suitability for a bariatric commode in terms of documented risk assessment.

The medical cause of death was
1a) Sepsis and bronchopneumonia
1b) traumatic perianal laceration

2 Hypertensive heart disease and cerebro-vascular accident

Mr Sketchley was a resident at Ashley House Nursing Home, in Cirencester, a residential facility run by BUPA. On 16th July 2017, Mr Sketchley was seated in a commode chair. He attempted to raise himself from the chair and in the process managed to dislodge the commode pan and flip the seat on the chair. The commode chair was a bariatric chair with a horse shoe design. This design means there is a gap at the front of the seat and it appears that on raising himself from the chair, one of Mr Sketchley’s legs became lodged in the gap thus causing the pan to dislodge and the seat to flip up.

Mr Sketchley’s body then fell between the gap in the front of the chair and in so doing his anus was impaled on one of the supporting bars beneath the seat (no longer in situ).

The injuries Mr Sketchley sustained caused his death the following day.

At the time of the incident Mr Sketchley was to be supervised. The evidence that I heard was the main carer thought that whilst on the commode Mr Sketchley was to be supervised at all times. The care plan dictated that generally Mr Sketchley was to be supervised regularly. I heard no evidence that staff understood exactly what level of supervision was required. I heard from Demelza James that it is deemed acceptable to not observe / watch a resident who is being supervised but just to listen to them. I heard no evidence that Mr Sketchley’s care plan stated this was a sufficient level of supervision, nor that there are any guidelines to assist staff when making decisions about the level of supervision a resident requires.