Wilhelmina Isobel Newton · Prevention of Future Deaths report

On 13th May 2013 I commenced an investigation into the death of Wilhelmina Isobel Newton, 98. The investigation concluded at the end of the inquest on 21st October 2013. The conclusion of the inquest was Medical cause of death
1a) Subdural Haematoma
b) Fall
Conclusion:
On the 14th May 2013, in her room at Grisedale Croft Residential Home the deceased was put into bed at about 03.00 hrs. At 04.30 hrs she shouted and was found to be lying on the floor next to her bed. Later that morning she was found to be unrousable and was admitted to Cumberland Infirmary where she died on 15th May 2013.
She died as the result of an Accident.

The deceased had a history of falls both before and after becoming a resident at Grisedale Croft. She had fallen out of bed and banged her head at 04.30 hours. She was not attended by a nurse until 09.45 hours shortly after which an ambulance was summoned. She was prescribed regular aspirin.

On the evidence heard it appeared there was no clear written plan , protocol or guidance to the staff as to how they should respond to a potential head injury to an elderly resident, particularly one receiving medication which had the potential to affect the blood’s clotting ability: the absence of such guidance may apply to other residential homes operated by the Council