Patricia Mary BARNETT · Prevention of Future Deaths report

On 19 March 2026 I commenced an investigation into the death of Patricia Mary BARNETT aged 84. The investigation concluded at the end of the inquest on 21 May 2026. The conclusion of the inquest was that:
On 13 March 2026, at the Peterlee Care Home, County Durham, the deceased died due to a head injury sustained in an unwitnessed fall at the Peterlee Care Home on 26 February 2026.

Mrs Barnett suffered from Alzheimer's Dementia and was unable to mobilise independently. During the late evening of 26 February 2026 Mrs Barnett was in the lounge area of the care home. She had been given medication to "manage her behaviour" and was reported to be sleepy. She was known to be at high risk of falls due to attempting to mobilise without assistance. There had been members of staff present in the lounge are in order to monitor the residents (including Mrs Barnett), but the staff had left the area to assist another resident to go back to their room. While Mrs Barnett was left unsupervised in the lounge area, she had an unwitnessed fall. As a result of that fall she suffered a serious injury to her head, which resulted in her death on 13 March 2026.

I am concerned that Mrs Barnett was left unsupervised in the lounge area. I am concerned that there is risk that future deaths could occur if residents who are suffering from reduced mobility and cognitive impairment and who are at high risk of falls are left unsupervised in the lounge area of the care home.