CHARLES EVAN GRAINGER · Prevention of Future Deaths report

On 17 December 2013, an investigation was opened into the death of CHARLES EVAN GRAINGER which was concluded on Wednesday 09 May 2018. The conclusion of the inquest was Accidental death and the medical cause of death was accepted as being 1a. Bronchopneumonia, 1b. Central Cord Syndrome. During proceedings, the Court heard Pathology evidence which confirmed that Mr Grainger had essentially died from complications of Central Cord Syndrome following injuries sustained after a witnessed fall which occurred at Milford House Care Home on 24 November 2013.

1. The Court heard evidence that Mr Grainger was admitted to Milford House Residential Unit on 20 September 2013, following a fall which occurred at his home, resulting in a fracture to his right scapula and hospital admission at The Royal Derby Hospital. Following hospital treatment, he was discharged to Milford House for mobility rehabilitation which took place in conjunction with the Community Care Support Team/Occupational Therapy Team. Whilst Mr Grainger was known to have a long established history of falls which his Social Worker, ████████ confirmed during her oral evidence, she stated that she was never required to share this important information with Milford House at the time they undertook his Pre-Assessment Admission, as his placement was funded by Health (now known as CCG), rather than the Local Authority. When challenged as to whether the system or process could be wrong she replied “maybe”.

2. Following Mr Grainger's witnessed fall on 24 November 2013, ████████ was also tasked to undertake initial investigations into the circumstances that led up to Mr Grainger's fall at Milford House. During evidence, ████████ stated that she did not feel it necessary to request, review or retain Mr Grainger's falls risk assessment documentation to satisfy herself that he had received the necessary care. She made a number of assumptions and her enquiries lacked basic details which should have included requesting and reviewing the falls risk assessment. Her enquiries were slipshod and did not withstand basic scrutiny when investigating concerns of this nature.

(1) Relevant information regarding Mr Grainger's falls history could not be shared by his Social Worker with other relevant Multi Agencies such as Milford House or the Health Team at the time his Pre Admission Assessment was undertaken as the process/system did not allow it. Milford House, the Local Authority and the Health Team should have all worked together, more cohesively to ensure they were working in Mr Grainger's best interests. Failure of Multi Agencies to work more cohesively in the future by sharing a patients past medical history, including previous falls history could result in vital information being missed and future deaths occurring.

(2) ████████ did not consider it important or necessary to request, review or retain copies of Mr Grainger's falls risk assessment as part of her basic investigation enquiries. Failure to undertake a basic and proper investigation could result in future deaths occurring.