Michael Yemm · Prevention of Future Deaths report

On 8 October 2020 commenced an investigation into the death of Michael Yemm aged 77years. The investigation concluded at the end of the inquest on 2 February 2021. The conclusion of the inquest was Cause of Death 1a) Advanced Dementia and at 2 Fractured Neck of Femur, Ischaemic Heart Disease.
Conclusion- Natural Causes contributed to by several falls and fractured neck of femur.

Mr Yemm had a complex medical history including diabetes, hypertension, LVF, hypothyroidism and thyrotoxicosis. He had developed vascular dementia in 2017. He was cared for at home by family until his care needs increased. He was admitted to hospital and discharged to a residential home, despite protests from his family that a nursing home was safer and more appropriate. He had several falls whilst there and was admitted to hospital again. Every time he was admitted and discharged, he had to isolate (covid) upon his return he the care home, exacerbating his distress. After his second admission the manager of the care home told the hospital that they would not accept him back as his needs could not be met by them. Despite this without notifying the care home, Mr Yemm was dropped off by hospital transport and the home had no option but to keep him as he was left there. They did manage to obtain extra help, but his care needs increased, and he was again admitted to hospital. He had an in-patient fall after climbing over raised bed rails in a bay with staff present and fractured his left hip which required and hemirthroplasty. The operation was successful, but Mr Yemm deteriorated and died in hospital with his family at his bedside (not being informed as the consultant report stated)

That Mr Yemm was placed into a totally unsuitable and unsafe residential setting. Shortly after his arrival, the next day, the manager contacted Mr Yemm's social worker and told them they couldn't look after him properly. Despite this he was left in this care home. ████████ wrote to the Director of Adult Social Services asking for help in finding a suitable placement and did not receive the courtesy of a reply. She was also told that after his falls that he had hairline fractures of his left hip before the fall in hospital.

The hospital dropped Mr Yemm off back at the care home without any warning after being informed that they could not have him back. He was also discharged on insulin which the home could not administer as they do not have trained nursing staff.

That he was able, in a cohorted patient bay, to climb past raised bedrails, he did not have a lowered bed, whilst staff were present. A cohorted bay has extra staff to deal with challenging patients and fell fracturing his hip, necessitating surgery. For the whole of his stay Mr Yemm was agitated, confused anxious and distressed, he had to move wards because of the need for surgery which further exacerbated his condition.

[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) The care home placement
(2) The hospital discharge despite being told they couldn’t send him back, and just leaving him there.
(3) The in-patient fall and care of dementia patients.