Phyllis Margaret LETCHER · Prevention of Future Deaths report

On 15th March 2018 I commenced an investigation into the death of 91 year old Phyllis Margaret LETCHER. The investigation concluded at the end of the inquest on 2nd August 2018. The inquest found that Phyllis Margaret LETCHER died on 12th March 2018 at Royal Cornwall Hospital Truro from trauma following an unwitnessed fall.

My conclusion as to the death is that it was an Accident.

The medical cause of death has been established on the evidence as -

1a traumatic subarachnoid haemorrhage
1b fall
II dementia, atrial fibrillation

Mrs Letcher died from injuries sustained after falling down the staircase at Crossroads House Care Home, Scorrier, Redruth.

Mrs Letcher’s previous medical history included vascular dementia and atrial fibrillation with a history of falls but no injuries sustained. Mrs Letcher had limited and declining mobility – she had a stick but did not use it.

Mrs Letcher was cared for by her family until February 2018, when following a social services assessment she was admitted to Crossroads House Care Home.

Crossroads House is a specialist care home for those suffering from the various forms of dementia.

Mrs Letcher was found at the foot of the staircase, staff having heard her fall on 2nd March 2018. A traumatic head injury sustained in the fall led to her death on the 12th March 2018.

To the knowledge of staff, Mrs Letcher had never used the staircase prior to the fatal fall. Access to the staircase is gained through a bolted stairgate which does not require a key or a fob, and can be manually unlocked.

(1) The absence of live CCTV monitoring of the staircase and other communal areas. The court heard evidence that whilst there is CCTV recording of the corridors it is not by way of a live monitored feed and does not cover the staircase.

(2) The absence of a key fob access through the stairgate. The court heard evidence that whilst access from the residential quarters is controlled by key fob there is no such control of access to the staircase.

(3) The absence of an alarm in the event that the stairgate is left open. The court heard evidence that the stairgate has on occasions been left open allowing unrestricted access to the staircase.