Ruth Jones · Prevention of Future Deaths report

On 23RD June 2020, I commenced an investigation into the death of Ruth Jones. The investigation concluded on the 19th January 2021 and the conclusion was one of Narrative: Died from natural causes contributed to by the recognised complications of an accidental fall.

The medical cause of death was
1a) Bronchopneumonia
II) Frailty, Dementia, Hypertension, Fractured Neck of Femur

Ruth Jones resided at The Beeches Care Home. She was at risk of falls. On 17th June she showed signs of being unwell. Her GP remotely diagnosed suspected Covid 19 and she was isolated in her room with staff observations and use of sensor mats to reduce her risk of falls and ensure her wellbeing. She fell whilst unobserved. She was admitted to Tameside General Hospital, where a fractured neck of femur, bronchopneumonia and possibly Covid 19 were identified. Her Covid 19 test was negative. She was not fit for surgery and it was proposed she be discharged to the Care Home.

On 20th June, she deteriorated and died at Tameside General Hospital from bronchopneumonia exacerbated by the fracture

1. The inquest heard that Mrs Jones was frail and at risk of falls. The home had a falls risk plan in place that was based around her being observed during the day in communal areas. The home was not staffed to provide one to one observations for residents required to self-isolate. As a result when Covid 19 was suspected by the GP, and the home were directed to isolate her she could not be observed by staff as would generally be the case in the day. The home took some steps with sensors to ensure they were aware if she stood up whilst in her room but could not provide continuous observation. It was unclear how homes were being advised to safely manage residents at risk of falls where isolation was required. The home were unaware of any guidance that they should follow to manage the risk.

2. When Mrs Jones had to go to hospital she was sent alone and her family could not go with her due to Covid 19 restrictions. The inquest heard that Mrs Jones was frail and vulnerable. The inquest was told that the unsupported presentation/assessment of vulnerable, frail and elderly patients such as Mrs Jones presented significant problems to clinicians in terms of effective communication and understanding their health baseline to support appropriate and timely clinical decision making.