Frederick Bevan · Prevention of Future Deaths report

On 07/10/2016 I commenced an investigation into the death of Frederick Bevan. The investigation concluded at the end of an inquest on 1st March 2017. The conclusion of the inquest was Accidental Death.

Mr Bevan passed away on 4/10/16 at Bromford Lane Care Centre, 28 Fairholme Lane, Washwood Heath, Birmingham as a result of a head injury following a fall at the home on 22/9/16. Mr Bevan had been a resident of the Home since June 2014 and was subject to a Deprivation of Liberty Safeguarding Order due to his dementia. His health had deteriorated in the summer of 2016 with a number of falls recorded by the Home. On 22/9/16 he suffered another fall which was witnessed by a staff member at the Home. Paramedics attended the Home promptly and Mr Bevan was admitted to Heartlands Hospital quickly. Following medical assessments it was concluded that no treatment or procedure would be beneficial to him. The decision was taken to return Mr Bevan to Bromford Lane to ensure his remaining days were as comfortable as possible. He passed away shortly afterwards at the Home.

Based on information from the Deceased’s treating clinicians the medical cause of death was determined to be:
1(a) SUBARACHNOID HAEMORRHAGE
1(b) FALL
1(c) DEMENTIA
2 HYPERTENSION

I was satisfied that Mr. Bevan’s fall was witnessed by a carer████████ However, two paramedics who attended in response to the 999 call following the fall both gained the clear understanding that the fall was not witnessed, they described that there were 4 or 5 members of staff present and the scene appears to have been somewhat chaotic. The likely explanation for the paramedics misunderstanding is that a clear hand-over of the history of the incident was not provided by the witness████████, but rather the nurses who has responded to the emergency call ‘took over’. This was accepted as a potential explanation by the home manager Judy Williams, who informed me that the policy is that the lead nurse should give the incident history to the paramedics: my concern is that if the history is not provided by the witness (regardless of whether they are a carer or a nurse) there is a risk that the correct history will not be given to emergency services which in some cases could have a detrimental effect on treatment.