Anne Shirley Scott · Prevention of Future Deaths report

The investigation into the death of Anne Shirley Scott was opened on the 2nd October 2014. It was concluded by way of an inquest on the 3rd March 2015. The verdict was accidental death and the causes of death were 1(a) Renal Failure 1(b) Rhabdomyolysis (clinically) & 1(c) Un-witnessed fall.

Anne Scott had an unwitnessed fall over night and was found by her carer in the morning of the 29th August 2014 crouched over in a cupboard at her home address, ████████. She was admitted to the Royal Cornwall Hospital, Treliske, Truro and diagnosed with acute kidney injury secondary to Rhabdomyolysis. She had significant bruising to her legs. Despite being started on haemodialysis, her renal function deteriorated and she was discharged on 16th September to her daughter's house for end of life care and she died on 19th September 2014.

Mrs Scott was prone to urinary tract infections (UTI's) during which she became confused and vulnerable to falls.

A ‘Telehealth’ monitoring device was put in place; however, the care provider did not appreciate the information provided by the device and act on it.

1. That special health monitoring devices are being used to monitor health conditions in patients who are receiving care in the community. However the care providers do not have the necessary training to be able to understand how the device operates, the information it provides and appropriate action to take, dependent on the information from the device, in conjunction with other observations.

At the inquest we heard that this matter was referred to the Safeguarding Adults Board and some learning points had been identified for the care providers. In particular, it was known that Mrs Scott was prone to urinary tract infections and whilst suffering from these infections Mrs Scott was known to become confused. A special health monitoring device (Telehealth) was in place. The care provider failed to identify the urinary tract infection prior to admission. These were addressed in the Adult Safeguarding Board learning points.

████████ (Social Worker) and ████████ (Care Provider Representative) confirmed changes were being considered but could not confirm if recommendations were being implemented. Both the representative of the Safeguarding Adults Board and the care provider consider that a Regulation 28 report would assist in embedding the Safeguarding Adults Board recommendations which had countywide implications.