Anoush Summers · Prevention of Future Deaths report

On the 22nd January 2024 Assistant Coroner Sarah Bourke began an investigation into the death of Anoush Summers who died aged 77, on the 14th January 2024 at Homerton University Hospital, Homerton Row, London, E9.

The investigation concluded at the end of the inquest on 6th June 2024 conducted by myself, Assistant Coroner Edwin Buckett.

I made a determination at inquest that the deceased died as a result of hypothermia which resulted from a fall at home following a long lie.

The narrative conclusion was as follows:

1. The deceased was a frail lady who was prone to falls. She lived at home, alone, with carers who visited her twice a day. She had a wrist alarm.
2. The wrist alarm was reported as broken and not working on the 6.1.2024, but it was not repaired or replaced.
3. Sometime after 4.45pm on 11.1.2024, the deceased fell at home. She was found the next day on the 12.1.2024 at 9am, by a carer, wearing her wrist alarm and taken to hospital where she died on 14.1.2024 of hypothermia.
4. The absence of a working wrist alarm prevented her from being found sooner that she was and probably contributed to her death.

Evidence was given that:

1. Although the wrist alarm had been reported as broken and not working on the 6.1.2024, this was not replaced or repaired by the company engaged by the local authority to provide this service before the deceased fell at home between 11-12.1.2024.

2. At the time the deceased fell, she was wearing her wrist alarm but could not use it to summon help because it did not work.

3. None of the carers who attended on the deceased after 6.1.2024 ensured that steps were taken to replace the wrist alarm or report the matter to the local authority.

4. The last carer who attended on the deceased before she died, on the 11.1.2024, was not aware that the wrist alarm did not work as she had not read the care notes. No clear instruction was given to care workers about the extent to which they would be expected to read the care notes relating to service users.

5. None of the carers had been given any training, instruction, or guidance on the testing of wrist alarms to ensure they worked properly when attending upon service users.

6. There was no clear system identified between the company providing carers and the local authority, as to the duties and responsibilities of each in the reporting of faults with wrist alarms.

I rely on all the above matters.

I am concerned that there is a risk of future deaths arising in circumstances when vulnerable people, who live at home and are reliant of wrist alarms which have been reported as not working, but have not yet been repaired, may be unable to summon help.