Carol Ann CLEMENTS · Prevention of Future Deaths report

On 8 November 2022, I commenced an investigation into the death of Carol Ann CLEMENTS. The investigation concluded at the end of the inquest. The conclusion of the inquest was:-

Died as the result of an accident

The deceased was a resident at Perry Trees Centre following discharge from hospital after surgery to repair a hip fracture. Whilst at the centre, she was incorrectly assessed as being a medium risk of falls, when in fact, she should have been categorised as a high risk. She therefore did not have the correct level of supervision. On 2nd October 2022, Carol was found on the floor of her room, having been previously sat in her chair by staff. The fall was unwitnessed. Carol sustained a further hip fracture as a result of this fall. She was returned to hospital where further surgical fixation was carried out successfully. Initially, she recovered well post operatively, however, Carol developed Pneumonia. She had a RESPECT form in place from her earlier admission and therefore her care was comfort care only. Her pneumonia progressed to Sepsis, and she died on 23rd October 2022 in hospital.

Based on information from the Deceased's treating clinicians the medical cause of death was determined to be:

1a Multiorgan Failure

1b Sepsis

1c Pneumonia

II fixation of peri-prosthetic fracture of femur

1. Enhanced Supervision Levels training is not included on mandatory training programmes. Whilst some training sessions have been delivered by the trust to current staff members following this incident, I am concerned that new staff members joining will not be suitably trained in this area.

2. Falls risk assessment training is on the essential role training programme, however, I am concerned that this area is not covered suitably on induction of staff to the centre. This leaves a gap, particularly with agency staff, and I am not satisfied that with the current processes, agency staff will be fully versed on the completion of these risk assessments.
3. I was told that since this incident, falls risk assessments are being audited for compliance. I was also told that they are not being audited for correctness. I am therefore concerned that errors, and consequently, staff training needs, would not be picked up in these audits.