Clara Ellen Freeman · Prevention of Future Deaths report

On 13 March 2020 Mr Ian Arrow, the senior coroner for Plymouth, South Devon and Torbay commenced an investigation into the death of Clara Ellen Freeman aged 87. The investigation concluded at the end of the inquest on 19 February 2021.The conclusion of the inquest was the narrative conclusion;

Clara Ellen Freeman died at 02.37 on 6 March 2020 on Monkswell Ward, Derriford Hospital, Plymouth. The Deceased suffered an unwitnessed fall at Hart Care Nursing and Residential Home at around 21.30 on 3 March 2020. The Deceased was discovered by care staff but developed medical complications as a consequence of a period of approximately 4 hours being kept on the floor of her room immobilised before an ambulance conveyed her to hospital. The Deceased eventually succumbed in hospital to the medical complications.

The cause of death was;

I a Acute Kidney Injury

I b Rhabdomyolysis and Sepsis of Unknown Origin

II Heart Failure, Atrial Fibrillation, Frailty and Hypertension

The Deceased suffered an unwitnessed fall at Hart Care Nursing and Residential Home and was found on the floor of her room on her left side, conscious, but in pain. The ambulance service was contacted at 21:48, which advised that there was heavy demand for the ambulance services at that time and the average waiting time was 2 hours. Advice was given not to move the Deceased and to dial 999 if the Deceased's condition worsened. An ambulance arrived over 3.5 hours later at 01.23 during which time the Deceased was kept immobile on the floor. The care and nursing staff at the care home made 999 calls at 23.04 and 00.04 to ask when the ambulance would arrive and advising that the Deceased was in intense pain and (at 23.04) that the Deceased's temperature and pulse had risen. Observations by the nursing staff also recorded that the Deceased's oxygen saturations reduced during the wait and that latterly the Deceased's colour appeared cyanosed. This information was not handed over in the telephone calls nor was any concern raised about the risk to the Deceased being kept immobile over such a long period of time. The information would have been important to the call handler to assess whether the Deceased's condition was deteriorating or whether to refer the matter to a clinical adviser and potentially reassess the category of response.

[BRIEF SUMMARY OF MATTERS OF CONCERN]

(1) Evidence was heard regarding the level of proficiency of the care and nursing staff in dealing with the care of the Deceased after her fall and the interaction of staff with the ambulance service control centre call handlers, particularly in the passing of relevant information and any changes in the Deceased's condition.

It is requested that the training for care and nursing staff be reviewed to consider;

a) Effective interaction with the ambulance service and other medical service providers after an accident or medical emergency

b) Accurate recording of medical information including vital signs

c) Awareness of the risks of medical complications following falls and long lies.