Roger Harold Tombs · Prevention of Future Deaths report

On 25/05/2016 I commenced an investigation into the death of Roger Harold Tombs. The investigation concluded at the end of an inquest on 9th February 2017. The conclusion of the inquest was:
“Mr Tombs died as a result of an accidental fall. His needs had not been adequately re-assessed following a deterioration in his condition, which contributed to his death.”

In addition the jury made findings on the central issues of the case which were;
1. Was there any error or omission in the level of care provided to Mr Tombs that caused or contributed to his death? YES
2.Was there any error or omission in the sensor mat system that caused or contributed? NO.

On the 4th May 2016 at 03:30, Roger Harold Tombs died at Queen Elizabeth Hospital, after admission following a fall at Sunrise Care Home in Knowle on the 3rd May 2016. Roger was subject to a Deprivation of Liberty Safeguarding Order, due to his learning disabilities. He was at high risk of falls and had an increase in falls leading up to his death.

Following a post mortem, the medical cause of death was determined to be:
1a BRONCHOPNEUMONIA
1b SEVERE TRAUMATIC BRAIN INJURY
2 DEMENTIA (DIFFUSE LEWY BODY TYPE)

1. The evidence was that fall sensor mats had been placed either side of Mr. Tombs’ bed on top of crash mats. At the time of his fall on the 3rd May 2016 the sensor mats did not sound an alert
2. The instructions for use of the sensor mats state they should be placed on a hard floor.
3. The investigating police officer from the public protection unit gave evidence that she was concerned that the crash mats below the sensor mats would reduce the effectiveness of the sensor mats and this could possibly be the reason the mat didn’t sound (there were other possible explanations).
4. The evidence was that Sunrise of Knowle is still placing sensor mats on top of crash mats.
5. No expert opinion has been sought on this practice but the evidence of the investigating police officer was that the managing director of the local distributors of the mats told her this was an unsafe practice in his view.
6. It is my opinion that there is a risk that the effectiveness of the sensor mats is being reduced by placing them on crash mats and if this is the case they may not sound when vulnerable residents are mobilising especially when there is a risk of falls, injury and potentially death.