JOHN HENRY WILSHER · Prevention of Future Deaths report

On 30 December 2013 I commenced an investigation into the death of JOHN HENRY WILSHER, aged 96 years. The investigation concluded at the end of the inquest on 1 August 2014. The conclusion of the inquest was medical cause of death 1a) Subdural Haematoma; 1b) Frailty (Recurrent Falls); c) Old Age and short-form conclusion “Accidental Death”.

Mr Wilsher was resident in Springdale Care Home (“the Care Home”). His condition deteriorated in November 2013 and he had falls on 18 and 25 November 2013. Mr Wilsher was seen by his GP who referred him to Community Services, Norfolk County Council (“NCC”) for assessment, being of the view that Mr Wilsher was not safe at the Care Home due to the falls. The Care Home was not made aware of the referral. Mr Wilsher deteriorated and was seen again by the GP on 27 November 2013 when he was referred to the Norfolk & Norwich University Hospital (“NNUH”) for assessment. A CT scan was commissioned which showed right extradural haemorrhage and bilateral subdural haemorrhage which were considered to be several weeks or even months old. It was agreed there was to be no intervention and Mr Wilsher was to be kept comfortable. Mr Wilsher was found to be stable and plans were made for discharge.

NNUH contacted the Care Home to see whether they felt able to care for him due to his frailty. The Care Home required him to be able to transfer with the aid of one person. He was assessed by NNUH Physiotherapist on three occasions and stated to be able to be so transferred, although it was accepted that his mobility was variable. He was accepted back at the Care Home on this basis. He returned to the Care Home on 7 December 2013. The Discharge Letter gave the Primary Diagnosis as “Right frontal extradural haemorrhage + bilateral subdural haemorrhage” and Secondary Diagnoses and Complications as “Urosepsis”. In evidence, the Secondary Diagnoses was inaccurate. The Care Home quickly became aware they could not cope with his mobility and Mr Wilsher’s family made arrangements for him to be transferred to a nursing home on 19 December 2013. In the meantime, on 13 December 2013, Mr Wilsher was assessed by NCC Community Services Adult Care, when no further action was taken in view of Mr Wilsher’s impending transfer to a nursing home. The result of the Nursing Needs Assessment, carried out on 10 December 2013, was not available as at 13 December 2013. Mr Wilsher died on 21 December 2013.

(1) The information contained in the NNUH Discharge Letter is inaccurate;
(2) Concerns were raised by the GP and a referral made to NCC Community Services on 25 November 2013 as to the suitability of the Care Home in providing care to Mr Wilsher due to his deteriorating condition. He was admitted to NNUH on 27 November 2013 for assessment and plans were made for discharge to the Care Home. Neither NNUH nor the Care Home were aware concerns had already been raised (prior to a further deterioration in his condition) as to the adequacy of the Care Home to cope with his needs. On Mr Wilsher’s discharge to the Care Home it quickly became apparent they could not cope with his needs.
(3) An assessment was carried out by NCC Community Services on 13 December 2013 by which time Mr Wilsher had been admitted to NNUH and discharged and plans were already in place for his transfer to a nursing home.
(4) The outcome of the Nursing Assessment carried out on 10 December 2013 was not available at the time of the Community Services Assessment.