Sheila Ann Hadfield · Prevention of Future Deaths report

On 2nd October 2017, I commenced an investigation into the death of Sheila Ann Hadfield. The investigation concluded on the 17th September 2018 and the conclusion was one of Narrative: Died from the recognised complications of a natural cause exacerbated by a period of immobility following an accidental fall.
The medical cause of death was 1a Sepsis; 1 b Left sided empyema and purulent pericarditis;1 c Left sided bronchopneumonia

Sheila Ann Hadfield had a long standing mental health disorder of paranoid schizophrenia. She resided at Chester House, a residential care home. As part of her illness she self-neglected including poor personal hygiene and refusal of food. She would regularly stay in her room for significant periods of time and refuse access to care home staff. On 17th August 2017 it was identified that a best interest meeting would be beneficial as the home was struggling to cope. There were limited opportunities for placement elsewhere.

She went to her room on 21st September 2017. She did not come out for meals on 22nd September and refused access to her room. At about 14.00 on 22nd September 2017 she was found on the floor of her room by care staff. An ambulance was called and she was transferred to Stepping Hill Hospital. She was treated for sepsis. On 19th September 2017 she died at Stepping Hill Hospital from sepsis.

1. The inquest heard that the home that Mrs Hadfield was placed in struggled to cope with her needs. However, there was a national shortage of suitable beds for individuals of a similar age to Sheila Hadfield with her complex mental health needs. The majority of available care provision was dementia beds which would have been unsuitable. The inquest was told that this meant that had Mrs Hadfield not remained where she was she would have had to go onto a mental health ward on a voluntary basis or been sectioned if she had refused.