Amy Chiverall · Prevention of Future Deaths report

On the 9th July 2020 I commenced an investigation into the death of Mrs Amy Chiverall

Mrs Chiverall was a resident of Royley House Care Home, Lea View, Royton. On the 1st July 2020 she had an unwitnessed fall in her room. The Court heard evidence she was a moderate risk of falls. Her call bell (which are fixed items) was in her room but not within her reach. Her fall is likely to have occurred some 1-2 hours before she was found.

Medical attention was not sought in a timely manner and post fall observations were not conducted in line with the Care home policy. When she was admitted to hospital on the evening of the 2nd July 2020 she was found to have multiple rib fractures and a traumatic pneumothorax. Mrs Chiverall died on the 3rd July 2020.

The Court heard the home do not use pendant call alarms. This was described as a business decision. The Home has 18 residents of mixed falls risk but less than half would be of a moderate or high risk of falls. The Court was concerned that for those residents a fixed call bell may not be of assistance, as in this case, as it would be out of reach when required.