Dorothea Jean Parr · Prevention of Future Deaths report

Dorothea Jean Parr died on 28th March 2016. An inquest was opened on 12th April 2016 and concluded with Inquest hearing on 20th December 2016. The conclusion of the inquest was accident and the medical cause of death was found to be 1a) Pneumonia, 1b) Left Neck of Femur Fracture (post op) 1c) Fall II) Ischaemic Heart Disease

Dorothea Parr had an unwitnessed fall on the night of the 21st March 2016 at her home address, ████████ She had slipped/fallen from a recently delivered electric riser-recliner chair while it had been raised to the upright/standing position by using the hand controls while she was sitting in it. She was assisted back into the chair by carers the next morning as there were no apparent injuries or pain from the fall. Bruising of the leg/thigh was noted on 24th March and she was admitted to the Royal Cornwall Hospital and diagnosed with a fractured neck of femur. She underwent a dynamic hip screw procedure on 26th March 2016 after being optimized for surgery. She deteriorated and despite medical support died on 28th March 2016 from pneumonia as a consequence of the fall. There was no malfunction with the electric armchair. Mrs Parr was very frail and was unable to transfer or stand without assistance.

At the inquest the evidence showed that the electric armchair had been ordered by the Occupational Therapist and delivered by Tremorvah Industries (Mobility) at short/no notice to Mrs Parr’s address on 21st March 2016. No notification was given to the son – who had requested to be present when it was delivered nor to the Occupational Therapist or Kerrier Home Care Ltd who provided the carers who would assist Mrs Parr in using the new chair. This meant there was limited or no opportunity for the family and carers or district nurses to be trained for or appropriate risk assessments to be carried out prior to the use of the new equipment or at the time of the first use.

Mrs Parr was at high risk of falling. She was very frail and dependant on the carers for all her needs. She was not able to mobilise alone and required at least one carer to transfer. She would sit in the chair until the carers assisted her. The electric chair was provided on the day before she was found fallen. It appeared that Mrs Parr managed to use the controls to place the electric chair into the standing position while she was sitting in the chair resulting in her falling to the floor. In the days prior to the fall she had become more confused.

The District Nurse Manger explained that it was the role of the District Nurses to carry out the Falls Risk Assessment for clients living in the community at risk of falling. The District Nurses were very dependent on other agencies to inform them of falls or changes to the risk of falls e.g. the delivery of the electric chair or changes in presentation which increase the risk of falls e.g. confusion. In this case District nurses were not informed of the fall on 21st March from the new electric chair and no requirement for this to be done and so there was a lost opportunity to provide input – which in this case could have been to deactivate the electric armchair while the carers were not present. Although there were informal procedures in place for district nurse notification, there were no formal protocols or procedures in place. There is a high mortality rate of elderly patients who fall and fracture their femur