John William Tugwell · Prevention of Future Deaths report

On 16th April 2013 I opened an inquest into the death of John William Tugwell who, at the date of his death was aged 79 years. The inquest was resumed and concluded on 22nd November 2013
I found that the cause of death to be: -
1a. Bilateral lobar pneumonia
1b. Acute subdural haemorrhage and cortical contusions
I concluded with Accidental Death.

On 6th April 2013 Mr John William Tugwell was found at the bottom of the stairs following an unwitnessed fall at the nursing home where he was a resident. At the hospital he was found to have sustained skull fractures and an extra cranial scalp haematoma. Very sadly he was not considered fit for surgery and he subsequently succumbed to his injuries on 9th April 2013.

• Although Mr Tugwell was clearly a falls risk given his documented history of previous falls at the home, he was allowed unsupervised access to the two sets of stairs at the home.

I would be grateful if you could re consider the appropriateness of allowing such vulnerable and unsupervised residents access to the stairs given the potential for serious injury.