Mrs Winifred Elliott · Prevention of Future Deaths report

On the 4th and 5th December 2016 I heard evidence in relation to the Inquest touching the death of Mrs Winifred Elliott.

Medical Cause of Death

I (a) Bronchopneumonia

(b) Immobility and lower limb fractures associated with severe osteoporosis

II. Chronic renal failure, dementia.

How, when and where and in what circumstances the deceased came by her death:

Winifred Elliott resided in Meadbank Care Home. She was assessed as non-weight bearing and requiring a hoist for all transfers with the assistance of two persons. A hoist was rarely, if ever used. She was transferred either by being lifted by one person, or transferred partially weight bearing with the assistance of a handling belt.
On 31/12/2015 she was transferred into bed using a handling belt. This necessitated rotation of her left leg. As a result of this the left leg fractured in four places. The injuries sustained caused or contributed to her death. Despite severe underlying osteoporosis if she had been transferred in accordance with her moving and handling plans , i.e. non-weight bearing this would not have occurred on the balance of probabilities . There was evidence of systemic failings in staffing levels, supervision, and communication that when taken together the failure to apply the moving and handling plan, constitute a gross failure. The death was therefore contributed to by neglect. She was admitted to Chelsea and Westminster Hospital on 2/1/2016 where despite care their injuries led to and caused her death on 10/1/2016.

Conclusion as to the death

Mrs Winifred Elliott died as a result of injuries sustained during a transfer from her chair to bed using techniques not recommended for her.

The evidence was that the staff generally had no time to read care plans and relied on staff handovers for information in relation to moving or handling. Hoists were at times slow to locate and there were often insufficient staff to effect two person transfer. They had been training in relation to the techniques to be employed but staff often ignored that training. There appeared to a culture of collusion with this by some of the more senior staff, for example the nurses.

Things do seem to have improved under new management.

Evidence was taken as to how it could be made completely clear to staff transferring residents how transfers should be effected for the individual resident, and there was consensus that a written display somewhere effective, e.g. above a residents bed or inside their door could act as an effective prompt to staff, especially for example agency or bank staff. Since transfers are happening in the public areas of the home as well as in residents’ rooms, and such information would not be confidential. It would be in the best interest of disabled residents to ensure that such matters could not be confused by staff.

Various methods for doing this such as a traffic light scheme were discussed in evidence but it would be for each home to come up with the most appropriate method for them.

I was also informed in court that such information was displayed previously but was removed on the instruction of the CQC due to misplaced concerns about confidentiality.

1. That information in relation to transferring residents has been removed from display next to the resident e.g. from above their beds or inside their rooms.
2. That the removal of such information has made it harder for busy staff to access such information.
3. That as such, some residents may be being inappropriately transferred and thus sustaining injuries that may cause to contribute to their deaths as in this case.
4. That all homes should display as appropriate such information.
5. That the CQC should advise all residential homes that they should come up with such a system and implement it forthwith.
6. That the CQC should inspect homes and confirm that such systems are in place.