KENNETH SMITH · Prevention of Future Deaths report

On 13th November 2020 I commenced an investigation into the death of KENNETH SMITH, aged 83. The investigation concluded at the end of the inquest on 20th May 2021. The conclusion of the inquest was a short conclusion of ‘Accident’.

The medical cause of death was:
1a) Acute on chronic subdural haematoma
1b) Fall

The deceased had a medical history that included known cognitive impairment and presumed vascular dementia, throat cancer and a previous subdural haematoma following an accidental fall.

From the 8th of October 2020 his care needs were being met at the Shannon Court Care Home in Bolton. He had presented as a high risk of falls, requiring constant and night supervision by a care worker.

On the 22nd of October 2020, the level of supervision was reduced to night-time supervision between (7pm and 7am). This was a decision made by the care home staff in consultation and agreement with Bolton Clinical Commissioning Group and the local authority.

At lunchtime on the 31st of October 2020, whilst suddenly stood up to self-mobilize from a chair in the dining hall, he was witnessed to suffer a fall from standing, face first to the floor. He was taken to the Royal Bolton Hospital, where he was diagnosed with a chronic subdural haematoma with compression on the left hemisphere and an acutely sizeable subdural haematoma. Surgery was not considered acceptable and was treated conservatively.

He progressively deteriorated - to the extent that, by the 3rd of November it was recognised that his condition was un-survivable, receiving palliative care until his death on the 9th of November 2020.

After a proposed re-assessment of the falls risk posed by the deceased on the 22nd of October 2020 the 14-day period expired on the 22nd and 29th of October established that the deceased was to suffer 6 falls between the 22nd and 29th of October 2020.

Two of these falls took place on the 22nd of October 2020 – the same date of the reduction in the level of care being offered.

The evidence from the care home indicated that there was no date that had been given for a future review. It was also accepted that there was no action taken to consider whether any fall or falls resulted in the Accident Record including no action taken on the 29th of October 2020 when the deceased suffered two falls, resulting in tears and a head injury.

Additionally, the evidence established that on release from hospital to the care home on the 6th of October 2020, the discharge clinicians had stopped the prescription of Trazodone due to its known sedative qualities. There was no evidence of this (as part of the falls risk assessment) being taken into account by carers adequately, or at all.

Care staff had only escalated concerns over the deceased's progressive agitation to a general practitioner on 30th of October 2020. This had resulted in a referral to the Older Persons' Mental Health Team. There was no evidence as to why further advice from a mental health practitioner was not sought earlier, or as part of the risk assessment on the 22nd of October 2020.

The nature and quality of the care received by the deceased between the 22nd and 31st of October 2020 reveal the following concerns:

1. The decision to reduce the level of supervision was suboptimal, incorrect and unlawful.
2. The failure to consider and specify a review date;
3. The lack of appropriate scaling up of care to meet identified problems or issues with the reduced level of care, with no prompt to act on urgent review.
4. Care plan guidance, whilst not triggered, was serious or untoward incidents review by the care home, the CCG, or local authority;