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Investigation and inquest
On 14/2/13 I opened the inquest into the death of Silvia Eileen Taylor, who at the date of her death was 81 years old. The inquest was resumed and concluded on 14/7/14.
I found that the cause of death to be:
1a – Ischaemic Heart Disease
I concluded with a narrative conclusion as follows:
On 8/2/13, Silvia Eileen Taylor was found to have died at her home address of ischaemic heart disease. She had earlier activated her emergency pendant for the attendance of the doctor, although several subsequent attempts by the doctors to contact her by telephone were unsuccessful. It is found more likely than not, that earlier medical intervention would not have affected the outcome.
Circumstances of the death
On 7/2/13 at 10.06pm Silvia Eileen Taylor activated her care alarm at her home address resulting in an immediate response from the Emergency Response Officer. Mrs Taylor complained of stomach pains and requested a Thamesdoc. The family was contacted soon after and informed that a GP was to attend within 25 minutes. Subsequently Thamesdoc doctors made several unsuccessful attempts to contact Mrs Taylor by phone at her home address. Upon the arrival of the Thamesdoc doctor at her home address at 2.30am her lack of response prompted him to contact the family to request a key to the premises. The family found upon arrival that they could not enter via the front door with the key since it had been bolted internally. The GP left to attend an emergency call after discussing matters with the family. Subsequently the police were called and entry was forced at 4am when Mrs Taylor was found to have died on her bed.
Coroner’s concerns
• Although initial reports from Mrs Taylor gave no concern for the need for urgent medical attention, unsuccessful attempts to contact her were not acted upon for several hours.
• The difficulties in establishing telephone contact with Mrs Taylor, were not conveyed to the family.
I would ask that you consider giving further consideration to the no speech call procedures in relation to after hours support.
Information checked against the published report and official responses