Phyllis Broomhead · Prevention of Future Deaths report

On 12/06/2013 I commenced an investigation into the death of Phyllis Broomhead, 90.
The investigation concluded at the end of the inquest on 06 July 2015.
Cause of death: Traumatic left sided subdural haemorrhage

The conclusion of the inquest was a Narrative conclusion:

Phyllis Broomhead became a resident at Lord Hardy Court in December 2012 due to her dementia and general care needs. Despite multi-agency support she continued to suffer falls between 11 February 2013 and the time of her death. Three of these falls led to significant injuries. On 9 June she fell from her bed whilst trying to reach the toilet and sustained a head injury from which she died later that day

Mrs Phyllis Broomhead suffered from advanced brain disease (dementia) as a consequence of which she was admitted to the Lord Hardy Court EMI Residential Home on the 18th December 2012. The home cared for her general care needs and her dementia needs. Despite multi agency input Mrs Broomhead suffered several falls between the 11th December 2013 and her death on the 9th June 2013. Of the falls she suffered three of them were significant and all required hospitalisation. A Safeguarding Alert was raised at the time of the second significant injury which was exited the day of the alert, after enquiries had been made. It was felt all appropriate measures were in place and Mrs Broomhead returned to Lord Hardy Court. The falls continued until fatal fall on 9 June 2013. Measures in place were not fully implemented.

(1) Staff employed at Lord Hardy Court EMI Residential Home require further training with regard to:

i. the head injury protocol, how this should be followed and the importance of doing so.
ii. record keeping.
iii. indicators and triggers to seek social worker input.

(2) With regard to the Safeguarding team, subject to the impact of any subsequent legislation, the importance of ensuring that any initial screening process following a referral is sufficiently detailed and objective to facilitate the making of safe, sound and informed decisions with regard to any future action which might be indicated or indeed before exiting the process. Furthermore, I heard evidence that there were three types of home available; care homes, EMI care homes and nursing homes. For residents who are clearly continuing to be at high risk of serious injury, as was the case here, consideration should be given to introducing or expanding any local procedures or protocols to ensure closer scrutiny and monitoring of such residents' progress. It seemed that although Mrs Broomhead was identified as being of high risk of falls, as it was felt that she neededn't amount to nursing needs there was no alternative but for her to remain in a care home.