Doris Taylor · Prevention of Future Deaths report

On 7th January 2014 I commenced an investigation into the death of Doris Taylor dob 3rd October 1931. The investigation concluded on the 31st March 2014 and the conclusion was one of Accidental Death. The medical cause of death was 1a Pneumonia and multi organ failure 1b Fracture neck of femur (operated) and II Meningioma, intracranial haemorrhage and hypertension.

On the 20th November 2013 she was admitted to Marbury House Care Home due to decreased mobility and pains in her back. She was assessed as being at high risk of falling. During the course of her stay she suffered 3 separate falls. It would appear that the second of these falls was due to a defective door-closer which caused the door to close knocking Mrs Taylor over.

The senior member of staff who attended the inquest to give evidence was unaware of the need to report such incidents to the Health and Safety Executive and further stated that she was not trained as to which matters are reportable under RIDDOR.

1. Staff training should include a full and clear understanding as to what constitutes a reportable incident and the managers should be aware of their duty to report such.
2. The door-closers on all doors in such an establishment should be in a safe working condition, and of such ‘strength’ as to be efficient in causing the door to close yet at the same time not so ‘strong’ as to make it dangerous as they close (as to knock over the person as happened to Mrs Taylor).