Eileen Pollard · Prevention of Future Deaths report

In September 2019 I commenced an investigation into the death of Eileen Pollard. The investigation concluded following an inquest on 28 February 2020 where the conclusion was:

• Natural Causes

On 19 February 2019 Eileen Pollard died at hospital following a deterioration of her health conditions whilst resident in Buckingham Care Home, Penistone.

Overnight on 27-28 March 2019, Eileen Pollard, who was resident at Buckingham Care Home for respite care, became unwell with the symptoms of a myocardial infarction. She was taken to hospital by ambulance on 29 March 2019 where she passed away two days after her admission. During the course of her admission Eileen Pollard raised concerns about the fact that she had been pressing her nurse call bell which was not answered or was not working. The medical evidence presented at inquest was clear that even if this was the case, the outcome for Eileen Pollard would not have been any different.

a) The call bells are checked daily as part of routine maintenance however the document which records the checks is pre populated with a ‘P’ for pass. This could lead to rooms being missed in the checks or a failure to correct a ‘P’ to an ‘F’ in the event of a fail. It may be the case that in the event of another patient requiring a call bell and it not working this could make a significant difference to the outcome for that individual and for that reason the maintenance arrangements are important.