George Renshaw · Prevention of Future Deaths report

On 1 March 2013 I commenced an investigation into the death of George Renshaw Brown who was born on 13 January 1925 and the investigation concluded at the end of the Inquest on 30 August 2013. The conclusion of the Inquest was that the deceased died from 1a) Pneumonia due to 1b) Cervical spine fracture and under Part II: Acute on chronic arterial cerebral haematoma and dementia and the conclusion reached by me was that of Accidental Death.

On Sunday 17 February 2013 the deceased, who was a resident at Mayfield Care Home, left the premises via a fire door and fell down some concrete steps. He fractured his cervical spine and thereafter developed pneumonia leading to his death.

(1) There is clear evidence given that Mr Brown was placed, properly, at Mayfield Care Home and that Mayfield Care Home were looking after him within the capabilities of that type of establishment. It soon became apparent to the Manager of that Care Home that they were unable to meet the needs of Mr Brown’s advancing dementia and whilst she brought this to the attention of the appropriate authorities nonetheless it took several months to have him moved to a suitable alternative accommodation. There seemed to be no or no proper and efficient system in place for a speedy re-assessment and transfer of patients whose condition is deteriorating rapidly.