Netlyn Mae ROBINSON · Prevention of Future Deaths report

On 23 October 2020 I commenced an investigation into the death of Netlyn Mae ROBINSON, age 78. The investigation concluded at the end of the inquest on 22 June 2021. The conclusion of the inquest was:

Narrative: Netlyn Mae ROBINSON had been a resident in Hillcrest Care Home since April 2020 while her house was renovated to accommodate her reduced mobility. On 2 October 2020 she returned home to ████████ Gilpin Terrace, Upper Wortley, with a care plan in place for three daily visits providing assistance general living. Mrs Robinson did not have a history of problems with eating. She had assistance to help prepare her evening meal on 3 October 2020. She was discovered the following morning still at the dining table having choked on her food.

MCCD: 1a Choking on food,
2 Ischaemic and Hypertensive Heart Disease

Mrs Robinson had capacity. In December 2019 Mrs Robinson had been admitted to hospital and then conveyed to a mental health care facility (The Mount). She was discharged The Mount on 15 April 2020 into a care home while appropriate alterations were made to her home to accommodate her mobility issues.

Social care were responsible for the alterations which included moving her bedroom downstairs and providing a commode to avoid her having to climb stairs to the bathroom. She had a care package in place for carers to visit three times a day for general living assistance.

There were no reports or records with regard to any eating difficulties. When she returned home on 2 October 2020 she was met by a social worker.

(1) In evidence it became apparent that there was no falls pendant or alarm provided on Mrs Robinson’s return home despite her previously having one when last at home. There appeared to be no process in place to check whether there was a fully operational alarm system in place when needed. Further that Mrs Robinson was not consulted about the lack of an alarm until she had arrived home, thus no process in place to provide a person with relevant information in order that they are able to decide whether or not to return to their home address without any form of alarm.

(2) The telephone line was not connected. There appeared to be no process in place to check that telephones are working and that a vulnerable person has the ability to call for assistance (emergency or otherwise) or communicate with friends/relatives.

(3) With a lack of alarm or phone line there was still no risk assessment as to how an alarm could be raised.

(4) The heating was not working/turned on and again there appeared to be no process in place to check premises had heating, running water or smoke alarms and therefore was fit and safe for a vulnerable person to return to.

(5) The social worker stated he had been trained on the job to risk assess. He had never been shown a check list for the numerous issues that need to be checked prior to allowing a vulnerable person to be returned home. This included checking on current medical needs (although Mrs Robinson did not have any reported issue regarding eating/chewing/swallowing the question was not asked by the social worker ensuring her safe return home)

(6) It was acknowledged that the home was owned by Mrs Robinson however there appeared no processes in place to outline what social services would and would not do to ensure that Mrs Robinson’s premises were suitable.