Ian Dixon · Prevention of Future Deaths report

On 5th July 2023 an investigation was commenced into the death of Ian Dixon, then aged 72 years. The investigation concluded at the end of the inquest on 13th December 2023. At the end of the Inquest, I recorded a narrative conclusion that Mr Dixon died as a result of traumatic brain injury following a fall on a background of chronic alcohol excess with cerebellar atrophy.

The medical cause of death being:

1a) Traumatic Head Injury
1b) Chronic Alcohol Excess with Cerebellar Atrophy

Ian Dixon was a recovering alcoholic and had a history of falls. He had been suffering from confusion, was unsteady on his feet and was awaiting a memory assessment.

Following an assessment by an Adult Social Care duty worker on 31st May 2023, a decision was made to expedite the installation of an additional handrail on his staircase to try to minimise the risk of falls. Prior to that meeting Mr Dixon had hurt his left arm and hand, and the additional rail would mean that he could hold it with his undamaged hand to stabilise himself on the stairs. The installation was to be completed through Stockport Homes and the expectation was that this would be completed within 3 days in accordance with the timeframe for an urgent request.

On 8th June 2023, Mr Dixon was found deceased following a fall at the bottom of the stairs in his home. The fall caused an extensive skull fracture with an acute right sided subdural haematoma.

A post-mortem examination showed chronic cerebellar atrophy, due to chronic alcohol excess which likely caused his confusion and ataxia, leading to falls. A police investigation confirmed that there was no evidence of suspicious circumstances or third-party involvement.

At the time of his death no handrail had been installed. The inquest heard that there is no process in place for the council to be notified when requested work is completed or if there are any delays in work completion. The Inquest also heard that the work had been marked as complete on the Stockport Homes system even though the handrail had not been fitted.

(1) The Inquest heard that there is no policy in place governing the interaction between Stockport Metropolitan Borough Council and Stockport Homes following a request for the installation of equipment. This means that there is no review undertaken to check whether urgent equipment has been installed, urgent repairs completed or if there are delays/issues with the works requested.