John Edward RILEY · Prevention of Future Deaths report

On 22 February 2024 I commenced an investigation into the death of John Edward RILEY aged 73. The investigation concluded at the end of the inquest on 15 November 2024.

The medical cause of death was:
1a) Neck Fracture
1b) Fall
1c)
2)

The conclusion of the inquest was:
Accident

Mr Riley suffered life changing injuries in a road traffic collision in 1976 and was dependent on others for his care. Mr Riley entered Manor House Residential Home in 2017 and was provided with personal care. His mobility was severely limited. Risk Assessments found that Mr Riley was deemed at low risk of falling out of bed. His bed was to be placed at the lowest setting when unattended and he was subject to two hourly checks at night time. On 8 February 2024, Mr Riley was checked at 01.10 hours and 03.00 hours. When checked at about 05.25 hours Mr Riley was lying on the floor with the bed frame under his neck. Emergency services were called and Mr Riley was declared dead at the scene. The evidence does not reveal the means by which Mr Riley came out of bed and onto the floor. Mr Riley died from a fracture to his neck.

Evidence was heard that observations were sometimes not carried out every two hours as required. In January 2024 observations were at on occasions and on one prior occasion to 8 February 2024 in February 2024.
Evidence were heard that some action has been taken by Manor House Residential Home to reduce late observations.
Evidence was also heard that some observations are still being carried out outside of the two hour period.