John William BIRD · Prevention of Future Deaths report

On 2 June 2014 I commenced an investigation into the death of John William Bird, aged 92 years. The investigation concluded at the end of the inquest earlier today.

I made a determination that Mr Bird’s death came about as the result of an accident, when he fell in his care home on the evening of Tuesday, 29 April 2014.

I recorded his medical cause of death as:
1a pneumonia
1b subdural haematoma
2 dementia and general frailty

Mr Bird fell at around 11.20pm, having gone to bed a couple of hours earlier. A carer was close by and immediately came to his room to assist. He was taken to hospital shortly thereafter, but later died from the injury sustained.

You were unable to detail in court the entirety of the falls risk assessment you had undertaken for Mr Bird, because you did not bring the record of the risk assessment to the inquest, despite the nature of Mr Bird’s death and a written request from my coroner’s officer.

However, you were confident that you had assessed Mr Bird as being at very high risk of falls, as a consequence of his level of cognitive impairment coupled with his ability to walk without assistance. (This is, of course, a very difficult combination.)

Yet the carer who found Mr Bird after his fall, did not appear to have any familiarity with risk assessments. Even allowing for possible language difficulties (the carer is not a native English speaker), he assessed Mr Bird’s ability to mobilise unaided as “fine”, and did not see any particular risks for him.

When I put the carer’s evidence to you in court, you told me that he should know about the risk assessments. You later agreed in evidence that, as manager of the care home, it is your responsibility to ensure that all staff are familiar with risk assessments and the resulting care plan for each resident.