Geoffrey Spencer · Prevention of Future Deaths report

Following the opening of an investigation on 31st May 2017, on 6th June 2017, Andrew Bridgeman, Assistant Coroner for Manchester South, opened an inquest into the death of Geoffrey Spencer who died on 28th May 2017 aged 90 at Tameside General Hospital, Ashton-under-Lyne. The investigation concluded at the end of the inquest which I heard on 5th October 2017.

The conclusion of the inquest was that Mr Spencer died from a respiratory arrest secondary to aspiration pneumonia. Whilst multiple serious medical problems placed Mr Spencer at risk of aspiration pneumonia, his death was contributed to by injuries sustained in an unwitnessed fall at his care home. At the end of the inquest, I recorded a narrative conclusion to this effect.

Mr Spencer first became a resident at The Lakes Care Centre in 2015 as a result of the progression of vascular dementia. Although initially Mr Spencer was relatively mobile, in November of that year he had a stroke which diminished his mobility and impaired his ability to swallow safely.

On occasion, Mr Spencer became agitated, and input was sought from the Mental Health team and the General Practitioner to try and mitigate this.

On 24th May 2017, Mr Spencer was particularly agitated, having had a restless night. At around lunchtime, he was thought to be seated in the lounge area of the Coniston Unit at The Lakes Care Centre, which at all times was meant to be under supervision of an attendant member of staff.

At around the time some residents were being helped to the dining room for lunch, Mr Spencer was observed to be on the floor, some distance away from his chair. The evidence at inquest did not disclose how Mr Spencer had come to be on the floor, and particularly whether or not this had occurred whilst the lounge was unintended.

Later that day, Mr Spencer was noted to be in pain. An ambulance was called, and Mr Spencer was taken to Tameside General Hospital where a fractured neck of femur was diagnosed.

Although Mr Spencer was initially placed on the trauma operating list on 25th May 2017, he was not considered fit for surgery. Mr Spencer developed symptoms of respiratory problems later that day, and treatment for aspiration pneumonia was commenced on 26th May 2017. Very sadly, Mr Spencer’s condition deteriorated further, and he died in hospital on 28th May 2017.

Notwithstanding the serious injury sustained by Mr Spencer, and the residual possibility that this was sustained in circumstances where the lounge area was unattended by a member of staff, it is a matter of concern that no formal investigation has been undertaken in relation to this incident by The Lakes.

Whilst evidence emerged in the course of the inquest of improvements to the Care Centre’s Falls Policy and more formal reporting and analysis of falls at The Lakes, it is a matter of concern that the absence of a formal investigation has reduced the potential for learning to be derived from this incident with a view to improving the safety of other residents.