Douglas Grey · Prevention of Future Deaths report

On 14ᵗʰ May 2012 I commenced an investigation into the death of Douglas Grey then aged 72 years. The investigation concluded at the end of the inquest on the 25ᵗʰ September 2013. I concluded the inquest with a narrative, the medical cause of death being right sided pneumonia due to an acute subdural haematoma.

1. The deceased had been in a residential home since 2008 and, as a result of pressure sores after discharge from hospital, was given an inflatable mattress which was placed on top of the original mattress on his bed.

2. There were no cot sides or other safety features used.

3. He suffered a fall from his bed on the day the inflatable mattress was installed. Staff removed the mattress as they were concerned over it ‘slipperiness’. He then suffered a second fall a few days later. The mattress was then advised to be removed by the district nurse.

4. A few days after the second of the falls he became unconscious and had to be transferred to hospital where he died, despite treatment, in the early hours of the 5ᵗʰ May 2012.

1. Evidence was given at the inquest that there was no clear written procedure or policy in place to ensure notification to the district nurses of delivery of equipment they had assessed as being needed, correct installation of that equipment and review of the equipment’s performance.

2. Evidence was given at the inquest that despite a clear written policy on recognising and reporting faults in equipment delivered for residents, carers did not appear to recognise the faulty nature of the inflatable mattress and act in accordance with the written policy of the home.