Arthur Thomas Adley · Prevention of Future Deaths report

On the 9th day of April 2016 I opened an investigation into the death of Arthur Thomas Adley , aged 92 years old. I opened an inquest on the 22nd day of April 2016. The inquest concluded on the 13th September 2016. The conclusion of the inquest was “Consequences of a fall”, the medical case of death was 1a Cardio respiratory failure, 1 (b) blunt force trauma to the head and neck and associated complications.

On the 8th April 2016 at about 7.30 Arthur Thomas Adley, who was a resident at Candle Court Nursing Home, was pushed by another resident and caused to fall striking his face and head on a table as he fell.

The resident who had pushed Mr Adley was regularly assessed with regard to his suitability to remain at Candle Court Nursing Home.

Steps were taken to protect other residents and the resident who had pushed Mr Adley by ensuring that there were no obstacles in that resident’s way.

On this occasion the member of staff looking after Mr Adley in the lounge at the nursing home was aware that the resident who was likely to push other residents was leaving the lounge but had left Mr Adley for a moment. In that moment the resident approached Mr Adley and pushed him over.

This incident happened at 7.30 in the morning.

Mr Adley was taken to hospital where he died the same day.

There were 10 incidents over 3 years where the resident who pushed Mr Adley touched other residents in a way that may have resulted in a fall and on some occasions did result in the resident being pushed and falling causing injury.

That the systems for safeguarding for residents who present a risk to other residents when placed in care homes did not prevent that risk to other residents.