Joan RIMMER · Prevention of Future Deaths report

On 17th January 2017 I commenced an investigation into the death of Joan RIMMER who was aged 92 years.

The investigation concluded at the end of the inquest on 3rd March 2017. The conclusion of the inquest was
Ia Advanced Stage Dementia
II Fractured Neck of Femur (treated)

On the 3rd March 2017 the inquest concluded that Mrs Rimmer had died from an Accidental death.

Joan Rimmer was 92 years of age with a past medical history of dementia, anxiety and stress reaction. She was a resident of Croxteth Park Residential Home which is for residents with early onset dementia. She was not on a deprivation of liberty authorisation.by Liverpool DoLS team. On the 28th November 2016, she suffered an unwitnessed fall. Joan had been left seated in her chair in her bedroom, whilst carers collected what they needed to see to her personal care. On their return they found her on the floor. A falls risk assessment was appropriately carried out. No doctor was called but on 28th November 2016 she saw the community matron as she was complaining of groin pain. He assessed recording his actions in the notes. His later witness statement included additional information with regard to there being no physiological sign of fracture and that she did not consent to go to hospital for an x-ray. As a result of the persistence of Mrs Rimmer’s neighbour a GP was called some 14 days. The GP attended and assessed Joan on 12th December 2016. He reports that she was shouting out but he felt that this was not due to her dementia, aware that she had suffered a fall he referred her for an x-ray. On 13th December 2016 she was referred to Aintree University Hospital and was found to have an intertrochanteric right hip fracture. She underwent a hemiarthroplasty and post operatively she stopped eating and drinking. Fluids and food were encouraged but eventually after discussion with family it was decided to palliate Joan until she sadly passed away on 16th January 2017.

Though there was no evidence that Mrs Rimmer’s death could have been avoided by earlier diagnosis of her fractured hip – the court is concerned that the Community Matron employed by Liverpool Community Health assessed her physiological response to a fracture without taking any physiological readings and further adjudged her to refuse to be x-rayed when a carer witness who was present has explained that the extent of her dementia on the 29th November was so severe she would not understand sufficient to give consent. This in part led to a two week delay before her hip fracture was diagnosed. In another case such standards of nursing could result in an avoidable death not being prevented.

The Matron did not attend the inquest due to leave however at the inquest the family were advised by the home that he was retired – the court do not know where the truth lies other than the elderly relatives were keen that the case was concluded without further adjournment.