Ronald Houchin · Prevention of Future Deaths report

On 6 September 2017 an investigation was commenced into the death of Ronald Houchin aged 84 years. The investigation concluded with an inquest on 20 November 2018.

The inquest was assisted with evidence from the manager of Rosehill Care Home, ████████, a social worker and a team manager from Barnsley Metropolitan Borough Council, and ████████ consultant in the care of the elderly.

The conclusion of the inquest was:

Ronald Houchin died as a result of falling at Rosehill House Care Home. Care plans and falls risk assessments were not carried out or reviewed regularly and when they were carried out, the recommendations were not followed. Had Rosehill Houses’ own recommendations been followed, Mr Houchin may not have fallen and sustained the head injury which caused his death.

Ronald Houchin began attending Rosehill House Care Home on 31.12.15 for day care and occasional respite care.
On 31.12.15 a falls risk assessment was carried out and records there was a medium risk of Mr Houchin falling and he should be assisted and supervised while walking.
On 10.05.16 Mr Houchin fell, unwitnessed, in the bathroom. No changes were made to is care plan and a further falls risk assessment was not carried out.
On 28.06.16 a further falls risk assessment was carried out and records there was a high risk of Mr Houchin falling. His care plan was not changed.
On 20.12.16 Mr Houchin fell, unwitnessed, outside. No changes were made to his care plan and a further falls risk assessment was not carried out.
On 18.05.17 Mr Houchin fell, unwitnessed, outside. No changes were made to his care plan and a further falls risk assessment was not carried out.
On 21.05.17 Mr Houchin fell, unwitnessed, outside. No changes were made to his care plan and a further falls risk assessment was not carried out.
On 27.05.17 Mr Houchin fell, unwitnessed, outside. No changes were made to his care plan and a further falls risk assessment was not carried out.
On 08.06.17 Mr Houchin fell, unwitnessed, in the lounge. No changes were made to his care plan and a further falls risk assessment was not carried out.
On 17.06.17 Mr Houchin fell, unwitnessed, outside. No changes were made to his care plan and a further falls risk assessment was not carried out.
One 19.06.17 Mr Houchin fell twice, unwitnessed, once in the lounge and once in the toilet. No changes were made to his care plan and a further falls risk assessment was not carried out.
On 24.06.17 Mr Houchin fell six times, unwitnessed, once in the bathroom, twice outside and three times in the lounge. No changes were made to his care plan and a further falls risk assessment was not carried out.
On 26.06.17 a further falls risk assessment was carried out and records there was a high risk of Mr Houchin falling. No changes were made to his care plan.
On 19.07.17 Mr Houchin fell, unwitnessed, in the bathroom and was admitted to hospital. He was found to have bilateral subdural haematomas.
On 31.07.17 he was discharged to Rosehill House Care Home. No changes were made to his care plan and a further falls risk assessment was not carried out.
On 10.08.17 Mr Houchin fell, unwitnessed, outside. No changes were made to his care plan and a further falls risk assessment was not carried out.
On 01.09.17 Mr Houchin was admitted to hospital with shortness of breath and presented as “..unwell and sleepy..”. A scan showed progression of the left sided haematoma.
Mr Houchin died on 05.09.17 at Barnsley General Hospital. The medical cause of death is:

1a. Aspiration pneumonia
1b. Subdural haematoma
II. Stroke, frailty, vascular dementia

Evidence was given before the Court that the falls risk assessment carried out on 31.12.15 was not followed. As such Mr Houchin was not assisted and supervised when mobilising.

Mr Houchin fell seventeen times between 31.12.15 and 10.08.17.

The falls risk assessment was updated twice between 31.12.15 and 10.08.17.

Mr Houchin died as a result of aspiration pneumonia caused by a subdural haematoma sustained in an unwitnessed fall.

In my opinion there is a risk that future deaths may occur unless a system is established within Rosehill House Care Home whereby falls risk assessments are conducted regularly and assessments and care plans are followed.