Pin
Get email alerts
Request correction
Investigation and inquest
On 3rd June 2025 I commenced an investigation into the death of Ronald PERRY . The investigation concluded at the end of the inquest on 31st October 2025. The conclusion of the inquest was narrative: Died from frailty contributed to by the complications of a fall sustained at the care home where he resided. The medical cause of death was 1a) Frailty; and II Recurrent Pneumonia, Vascular Dementia, Fracture of Left Neck of Femur (operated on), Bilateral acute Subdural Haematomas.
Circumstances of the death
Ronald Perry had become increasingly frail and was discharged from Tameside General Hospital to The Lakes Care Home on 12th March 2025. He was on anticoagulant medication. He had a series of falls following his admission to The Lakes. The first of these was on 14th March 2025. Following that fall, he then fell on 24th March 2025 and was taken to Tameside General Hospital and then discharged back to The Lakes. His family raised concerns about his falls risk. On 21st April he had a fall that was not escalated for medical advice and no additional fall risk assessments were carried out. He should have been escalated: On 25th April he had a further fall and was taken to Salford Royal Hospital via Tameside General Hospital. He had sustained a bleed to the brain and fractures including one to the neck of femur. He was operated on. He deteriorated and died at Salford Royal Hospital on 30th May 2025.
Coroner’s concerns
1. During the course of the inquest it was difficult to be clear at times as to what care had been delivered or what steps had been taken because the documentation relating to care and risk was poor.
2. The falls risk assessment documentation was incomplete and did not appear to have been updated after falls had occurred.
3. The falls policy regarding the need to seek medical advice where a resident on anticoagulation had a fall that had been unwitnessed did not seem to be widely understood by staff or adhered to on all occasions.
Information checked against the published report and official responses