Norma Kyte · Prevention of Future Deaths report

On 9 June 2023 I commenced an investigation into the death of Norma Kyte, 87 years old. The investigation concluded at the end of the inquest on 6 October 2023. The conclusion of the inquest was death by natural causes. The medical cause of death was 1a alzheimer’s disease, age related frailty 2 fall.
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Norma Kyte died on 4 June 2023 at Broomcroft House. On 2 May 2023 she had an unwitnessed fall at the nursing home. This fall did not trigger the sensor mat which had been placed on the floor and therefore was not identified by staff until she was checked upon. The mat used on the floor had been deemed appropriate to be used in this way by the nursing home, but did not cover all the area by the bedside and would not trigger unless it was directly stood upon. The care home were unable to identify if this was used in accordance with manufacturers instructions.
Norma was taken to Northern General Hospital for an x-ray and diagnosed with a right supracondylar femoral fracture. She was discharged with a full length cast on her leg.

Following this she was seen on numerous occasions by the GP for vacant episodes, agitation and reduced oral intake. Treatment was given but she continued to deteriorate. The Care Home Manager confirmed that when Norma returned to the home she had completely changed in presentation and that this had had a big impact upon her. She was last see on 2 June by the GP where she had further reduced responsiveness and oral intake. She continued to decline and passed away on 4 June 2023.

(1) The sensory mats being used on the floor next to the bedside are significantly smaller than the bed and will only trigger when directly stood upon. If a patient gets out of bed in a place not covered by the mat this will not be trigger a response from the care home staff and they will be unaware the patient is trying to move or has fallen.
(2) The sensory mats may not be being used in accordance with manufacturers instructions.