Stanley Bere · Prevention of Future Deaths report

On 29 April 2014 I held and concluded an inquest (and investigation) into the death of Stanley Bere, aged 89 years old. The formal conclusion was Stanley Bere, died on 4th June 2012 from congestive cardiac failure and bronchopneumonia. He had been immobile for some time following an assist fall on 31st October 2011, some 8 months earlier, in which he suffered a fractured ankle. This fractured ankle together with the subsequent infection contributed to his death.

Mr Bere had been a resident of the Villa Adastra nursing home since December 2009. He had during that time suffered a number of falls. On 31st October 2011 he had another fall. An incident report was completed where it was noted that he had suffered no injuries. The fall was not recorded at the time on the home’s Cardex system. Mr Bere had in fact sustained a serious injury in the fall to his ankle. It then appeared that there were many missed opportunities by the staff at the home to spot these injuries. The family raised concerns on a number of occasions but it was not until 8th November 2011 that action was taken and the true extent of Mr Bere’s injury was discovered. His ankle had been fractured in two places which was required to be pinned in the Hospital.. After this procedure he returned back to the Care Home. A few weeks later the District nurse realised that one of the implanted screws was visible and the area was infected. Again this was not picked up by the Care Home. Mr Bere was readmitted to hospital where the screws were removed and the infection was treated. As a result of the ongoing infection all the metalwork had to be removed and this took place on 23rd May 2012. Sadly Mr Bere did not recover from this medical intervention and he slowly deteriorated and died on 4th June 2012.

(1) There was evidence provided at the Inquest that showed that the Cardex system used at the home was not being properly completed. Dates, on occasions, appeared to be out of order and important information such where a patient had fallen was not being recorded. Family concerns also did not appear to always be recorded.
(2) Incident reports were being completed but in Mr Bere’s case his incident report was not followed up or updated even when further information was available as to the extent of Mr Bere’s injury.
(3) The lack of cross referencing or monitoring of these Cardex system and the Incident reports appears to have been the reason why Mr Bere’s injuries were not picked up soon by staff.