Peter McCarthy · Prevention of Future Deaths report

An Investigation was commenced on the Eleventh December 2023, and an Inquest opened on the Fourteenth December 2023, into the death of Peter McCarthy. The Inquest concluded on the Ninth October 2024.

Peter McCarthy died on the 30ᵗʰ November 2023 from heart failure and pneumonia.

The conclusion was that he died by Accident.

Peter McCarthy fell from his wheelchair at home on the evening of the 25th November 2023 when his wheelchair flipped over a slight ridge between the bathroom and corridor. He was not found until the following morning by his carer. She called an ambulance. She left the premises. Shortly thereafter a district nurse attended and made a further call to the ambulance which resulted in a quicker categorisation of the response. He was taken by ambulance to East Surrey Hospital and found to have sustained rib fractures and a subdural hematoma. He was given appropriate care, but he deteriorated and died on the 30th November 2023 from heart failure and pneumonia.

Following the inquest Care 4 U have put in place steps to ensure staff do not leave clients alone whilst they wait for ambulances.

However, I remain concerned that:

1. On her arrival the carer offered Mr McCarthy his daily medications, which included an anticoagulant. He refused to take it. Following the conclusion of the inquest I sought information from Care4U Healthcare as to what, if any, protocol they have to ensure that clients who have fallen are not given anticoagulant medication without medical oversight. I have been told that medication comes in blister packs and the staff would not know if any medication was contra indicated after a fall. To date no protocol has been provided to the Court to deal with this type of situation.