Beryl Simcock · Prevention of Future Deaths report

On 2 August 2021 I commenced an investigation into the death of Beryl Simcock, aged 90. The investigation concluded at the end of the inquest on 22 June 2022. The conclusion of the inquest was that Beryl Simcock died by accident.

Mrs Simcock lived in a care home due to her care needs arising from her dementia. Her condition deteriorated during the year leading up to her death following two bouts of Covid-19. Mrs Simcock suffered a number of falls within the bedroom of her care home. In the period leading up to her death she fell twice in March 2021 and then fell again on 10 June 2021. This last fall resulted in an impacted fractured neck of femur. This fall severely affected Mrs Simcock’s health and she was admitted to hospital. The fall occasioned a significant deterioration in her dementia and resulted in her spending most of her time in bed. She received treatment for medical problems arising from the fall but did not improve. She was then discharged on end of life care and died in a nursing home two days later.

Mrs Simcock’s care plans were not changed in light of her changing care needs. No proper falls risk assessments were undertaken within the care home. It is not possible to say whether or not falls measures could have been implemented which would have avoided the fall which led to Mrs Simcock’s death.

I was concerned about the lack of written policies for care planning and review. I was concerned that reviews of care plans and risk assessments were either not done (and the records falsified to suggest that they were) or that they were done by someone unsuited to the task. This was not identified despite audit activity during the relevant period.

I was also concerned that at times when Mrs Simcock was deprived of her liberty the care home did not ensure that her family were given adequate and timely information to enable them to provide independent scrutiny of the care and restrictions in place.

It is requested that consideration be given to:-

1. Taking steps to ensure that family members are informed of falls and other significant incidents experienced by residents, particularly where the resident concerned lacks capacity and / or is deprived of their liberty; and
2. Taking steps to ensure that risk assessments and care plans are regularly reviewed competently and that the records truly reflect what risk assessments and care plans have taken place.