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Investigation and inquest
On 3rd October 2017 I commenced an investigation into the death of Sheila ROSS. The investigation concluded at the end of the inquest on 21st December, 2017. The conclusion of the inquest was ACCIDENTAL DEATH (TO WHICH NEGLECT CONTRIBUTED)
Circumstances of the death
See Record of Inquest
The published report provides this section by reference to another part of the report.
Coroner’s concerns
(1) Mrs Ross became a resident at Carlton House Rest Home in October 2014 following having fallen and fractured her hip, yet even at this early stage a falls risk assessment was not completed for her.
The years went by and there were no falls but on the 9th December 2016 Mrs Ross had what was described in the GP’s letter as a fall. The Rest Home Manager described it as ‘slip’ - she slipped off the edge of the bed. This is not uncommon but in the absence of any falls over for over two years it’s worrying and should have triggered a falls risk assessment but it didn’t.
In July of 2017 Mrs Ross was admitted to hospital very unwell with sepsis due to coli cystitis. On her return to the Rest Home she was less well and more agitated, her sleep which had always been of irregular pattern became worse and she was wandering more. Physically, she apparently didn’t need a stick but her behaviour was such that it was believed she lacked mental capacity – an application was made and she was placed on a Deprivation of Liberty Safe Guarding Order from the 23rd August 2017. The assessments in connection with this highlighted her vulnerability and the fact that she needed 24 hour care and yet there was still no falls risk assessment carried out.
By the time she had the fatal fall on the 17th September when she fell down a flight of stairs (which led to a floor on the Rest Home that she had no need to visit) she still had no falls risk assessment.
It is, of course, entirely possible for falls to occur even in the best regulated of situations with all paperwork properly in place. However, if a falls risk assessment had been carried out it would have highlighted Mrs Ross’ inability to make any assessment of her own personal safety and there is a possibility that this fall could have been prevented.
Since this catastrophic injury there has been significant changes in personnel at the Rest Home and I have no doubt that steps have been initiated to ensure that all residents have the appropriate risk assessments and I also believe that the Inquest itself will be a catalyst to speed this process up.